Neuroactive steroids, compositions, and uses thereof

ABSTRACT

Described herein are methods of treating a disorder, e.g., tremor, e.g., essential tremor; depression, e.g., postpostum depression; and anxiety disorder, the method comprising administering to a human subject suffering from a disorder, e.g., tremor, e.g., essential tremor; depression, e.g., postpostum depression, an anxiety disorder with a neuroactive steroid or a composition comprising a neuroactive steroid (e.g., pregnanolone, allopregnanolone, alphadalone, ganaxolone, or alphaxolone).

CROSS-REFERENCE TO RELATED APPLICATION

This application claims priority from U.S. Ser. No. 62/305,279 filedMar. 8, 2016, U.S. Ser. No. 62/355,174 filed Jun. 27, 2016, U.S. Ser.No. 62/355,669 filed Jun. 28, 2016, U.S. Ser. No. 62/360,758 filed Jul.11, 2016, and U.S. Ser. No. 62/360,762 filed Jul. 11, 2016, all of whichare incorporated herein by reference in their entireties.

SUMMARY OF THE INVENTION

Progesterone and its metabolites have been demonstrated to have profoundeffects on brain excitability (Backstrom, T. et al., Acta Obstet.Gynecol. Scand. Suppl. 130:19-24 (1985); Pfaff, D. W and McEwen, B. S.,Science 219:808-814 (1983); Gyermek et al., J Med Chem. 11: 117 (1968);Lambert, J. et al., Trends Pharmacol. Sci. 8:224-227 (1987)). The levelsof progesterone and its metabolites vary with the phases of themenstrual cycle. It has been well documented that the levels ofprogesterone and its metabolites decrease prior to the onset of menses.The monthly recurrence of certain physical symptoms prior to the onsetof menses has also been well documented. These symptoms, which havebecome associated with premenstrual syndrome (PMS), include stress,anxiety, and migraine headaches (Dalton, K., Premenstrual Syndrome andProgesterone Therapy, 2nd edition, Chicago Yearbook, Chicago (1984)).Subjects with PMS have a monthly recurrence of symptoms that are presentin premenses and absent in postmenses.

A syndrome also related to low progesterone levels is postnataldepression (PND) or postpartum depression (PPD). Immediately afterbirth, progesterone levels decrease dramatically leading to the onset ofPND. The symptoms of PND range from mild depression to psychosisrequiring hospitalization. PND is also associated with severe anxietyand irritability. PND-associated depression is not amenable to treatmentby classic antidepressants, and women experiencing PND show an increasedincidence of PMS (Dalton, K., Premenstrual Syndrome and ProgesteroneTherapy, 2nd edition, Chicago Yearbook, Chicago (1984)).

Additionally, several lines of evidence suggest that cerebellardysfunction through the cerebello-thalamocortical pathway play a keyrole in essential tremor (ET) (McAuley 2000; Pinto 2003; Elble 2009;Schnitzler 2009; Deuschl 2009). Activation studies with positronemission tomography (PET) indicate abnormally increased regionalcerebral blood flow in the cerebellus both at rest and when tremor isprovoked by unilateral arm extension (Boechker 1994, Wills 1996).Post-mortem analysis revealed a 35% reduction of GABA_(A) receptors anda 22-31% reduction of GABA_(B) receptors in the dentate nucleus ofcerebella from ET patients (Paris-Robidas 2012). There is increasingevidence to support the use of neuroactive steroids, e.g., a neuroactivesteroid as described herein, e.g., progesterone and its metabolites; inthe treatment and prevention of tremor (e.g., essential tremor),depression (e.g., postpartum depression, major depressive disorder), andanxiety disorder.

SUMMARY OF THE INVENTION

The disclosure features, inter alia, a method, the method comprisingadministering a neuroactive steroid, e.g., a neuroactive steroid asdescribed herein, e.g., pregnanolone, allopregnanolone, alphadalone,ganaxolone, alphaxolone, or Compound 9 as described below, or apharmaceutical composition comprising a neuroactive steroid (e.g.,brexanolone) to a subject, for example to treat a CNS-related disordersuch as tremor, depression (e.g., postpartum depression, majordepressive disorder), or anxiety disorder. In some embodiments, theneuroactive steroid is formulated for parenteral delivery (e.g.,intravenous delivery (IV)). The disclosure features methods of treatinga subject having a CNS disorder, e.g., tremor, e.g., essential tremor;depression, e.g., postpartum depression; and anxiety disorder, themethods comprising administering to the subject a composition describedherein, e.g., a neuroactive steroid, e.g., pregnanolone,allopregnanolone, alphadalone, ganaxolone, or alphaxolone, andoptionally a cyclodextrin, e.g., a β-cyclodextrin, e.g., a sulfo butylether β-cyclodextrin, e.g., a β-cyclodextrin, e.g., a sulfo butyl etherβ-cyclodextrin, e.g., CAPTISOL®. The disclosure also features, interalia, compositions comprising a neuroactive steroid, e.g., pregnanolone,allopregnanolone, alphadalone, ganaxolone, or alphaxolone; andoptionally a cyclodextrin, e.g., a β-cyclodextrin, e.g., a sulfo butylether β-cyclodextrin, e.g., a β-cyclodextrin, e.g., a sulfo butyl etherβ-cyclodextrin, e.g., CAPTISOL®.

In an aspect, provided is a method for treating a human subject, themethod comprising: identifying a subject at risk of suffering fromdepression (e.g., postpartum depression) or an anxiety disorder; andadministering (e.g., orally, intraveneously) to the subject atherapeutically effective amount of a therapeutic agent (e.g., aneuroactive steroid as described herein (e.g., allopregnanolone)) or apharmaceutical composition comprising a therapeutic agent (e.g., apharmaceutical composition as described herein, e.g., brexanolone). Insome embodiments, the therapeutic agent is administered to the subjectwithin 3 days, 2 days, 1 day, or 24 hours of delivery of a baby (e.g.,within 12 hours, within 6 hours, within 3 hours, within 2 hours, within1 hour, within 30 minutes).

In some embodiments, the subject is identified to be at risk through ascreening method (e.g., Edinburgh Postnatal Depression Scale (EPDS),e.g., a score of 10 or more on the EPDS, a score of 13 or more on theEPDS). In some embodiments, the subject is identified to be at riskthrough screening instruments such as Patient Health Questionnaire (PHQ)in various forms or the Hospital Anxiety and Depression Scales orGeriatric Depression Scale.

In some embodiments, the subject has given birth. In some embodiments,the subject has given birth within 3, 2, or 1 days; 24, 20, 16, 12, 8,6, 4, 3, 2, or 1 hours; or 60, 45, 30, 15, 10, or 5 minutes. In someembodiments, the subject is due to give birth. In some embodiments, thesubject is due to give birth in 9, 8, 7, 6, 5, 4, 3, 2, or 1 months; 4,3, 2, or 1 weeks; or 7, 6, 5, 4, 3, 2, or 1 days. In some embodiments,the subject is in her third trimester of pregnancy. In some embodiments,the subject has an attribute, characteristic, or exposure (thatincreases the likelihood of developing a disorder as described herein,e.g., neuroactive steroid deficiency). In some embodiments, the subjecthas a chronic illness (e.g., cancer or cardiovascular disease), othermental health disorders (including substance misuse), or a familyhistory of psychiatric disorders. In some embodiments, the subject isdisabled or has poor health status due to medical illness, complicatedgrief, chronic sleep disturbance, loneliness, or history of depression.In some embodiments, the subject has poor self-esteem, child-carestress, prenatal anxiety, life stress, decreased social support,single/unpartnered relationship status, history of depression, difficultinfant temperament, previous postpartum depression, lower socioeconomicstatus, or unintended pregnancy. In some embodiments, the subject hashyperemesis gravidarum (e.g., severe form of morning sickness, e.g.,preventing adequate intake of food and fluids). In some embodiments, thesubject has had a complication in pregnancy (e.g., emergency C-sections,pre-eclampsia, hospitalization during pregnancy, concern about fetaldistress and admission of the baby to special care (NICU), the baby wasin the NICU). In some embodiments, the subject has had emotionallypainful or stressful experiences around pregnancy, childbirth, or earlyparenting (e.g., the subject was treated for infertility, had a previousmiscarriage or other pregnancy loss, delivery of muliples, specialneeds, colic or difficult temperament baby, had difficulty feeding). Insome embodiments, the subject has had a history of domestic violence,sexual or other abuse (e.g., abused as a child or as an adult). In someembodiments, the subject has had a traumatic childhood (e.g., loss of aparent, troubling relationship with parent). In some embodiments, thesubject has stress (e.g., loss of someone close, job loss, financialhardship, divorce, strain in a relationship, house move). In someembodiments, the subject has lack of social support. In someembodiments, the subject has a perfectionist or controlling personality.

In some embodiments, the therapeutic agent is a Selective SerotoninReuptake Inhibitor (SSRI).

In some embodiments, the therapeutic agent is a neuroactive steroiddescribed herein (e.g., a neuroactive steroid selected frompregnanolone, ganaxolone, alphadalone, alphaxalone, andallopregnanolone) or a pharmaceutically acceptable salt or isotopologuethereof). In some embodiments, the therapeutic agent is:

or a pharmaceutically acceptable salt or isotopologue thereof.

In some embodiments, the pharmaceutical composition is brexanolone. Insome embodiments, the therapeutic agent is Compound 9 or apharmaceutically acceptable salt or isotopologue thereof.

In some embodiments, when the therapeutic agent is allopregnanolone,then the therapeutic agent or pharmaceutical composition comprising thetherapeutic agent (e.g., brexanolone) is administered parenterally,wherein administering occurs through an intermittent intravenousinfusion or continuous intravenous infusion. In some embodiments, whenthe therapeutic agent is Compound 9, then the therapeutic agent orpharmaceutical composition comprising the therapeutic agent isadministered orally. In some embodiments, the neuroactive steroid orpharmaceutical composition comprising the neuroactive steroid isadministered chronically. In some embodiments, the neuroactive steroidor pharmaceutical composition comprising the neuroactive steroid isadministered acutely.

In an aspect, provided is a method for treating a human subjectsuffering from depression (e.g., postpartum depression or majordepressive disorder) or an anxiety disorder, the method comprisingadministering (e.g., orally, intraveneously) to the subject atherapeutically effective amount of a neuroactive steroid (e.g.,allopregnanolone) or pharmaceutically acceptable salt or isotopologuethereof or a pharmaceutical composition comprising a neuroactive steroidor pharmaceutically acceptable salt or isotopologue thereof (e.g.,brexanolone).

In some embodiments, the depression is clinical depression (e.g., severedepression), postnatal or postpartum depression, atypical depression,melancholic depression, Psychotic Major Depression (PMD), catatonicdepression, Seasonal Affective Disorder (SAD), dysthymia, doubledepression, Depressive Personality Disorder (DPD), Recurrent BriefDepression (RBD), minor depressive disorder, bipolar disorder or manicdepressive disorder, post-traumatic stress disorders, depression causedby chronic medical conditions, treatment-resistant depression,refractory depression, suicidality, suicidal ideation, or suicidalbehavior. In some embodiments, the depression is severe depression. Insome embodiments, the depression is postpartum depression. In someembodiments, the depression is major depressive disorder.

In some embodiments, the method provides maintenance treatment orpreventative treatment.

In some embodiments, the method provides acute treatment of thedepression (e.g., within 72 hours, 60 hours, 48 hours, 24 hours, 12hours, or less). In some embodiments, the method provides acutetreatment of the depression or anxiety disorder (e.g., provides relieffrom a symptom in less than 1 week (e.g., within 6 days, 5 days, 4 days,3 days, 2 days, 1 day, or 12 hours).

In some embodiments, the method provides rapid onset of efficacy (e.g.,rapid reduction in a symptom of depression or anxiety disorder; rapidlyaffective to reduce a symptom of depression or anxiety disorder, e.g., asubject experiences relief from a symptom of depression or anxietydisorder described herein within 1 week (e.g., within 6 days, 5 days, 4days, 3 days, 2 days, 1 day, or 12 hours)).

In some embodiments, the therapeutic effect is sustained (e.g.,effectively treats a symptom of depression or anxiety disorder and theefficacy is maintained for at least 1 day (e.g., at least 2 days, 3days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 1 month, 2months, 3 months, 4 months, 5 months, or 6 months, 7 months, 8 months, 9months, 10 months, 11 months, 1 year, 2 years, or more).

In some embodiments, the efficacy is maintained after a single course oftreatment (e.g., single dose, multiple doses, or cycle of treatment) ofa compound described herein (e.g., allopregnanolone) or pharmaceuticalcomposition described herein (e.g., brexanolone).

In some embodiments, the therapeutic effect is does not cause an adverseevent (e.g., does not cause a severe or moderate adverse event, e.g.,during treatment or 3 days, 7 days, 10 days, 20 days, 30 days, 60 days,90 days, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9months, 10 months, 11 months, 12 months, or more after treatment).

In some embodiments, the method includes a course of treatment withmultiple dosages or cycles of treatment (e.g., a first dose or cycle oftreatment is a parenteral dose such as an i.v. dose, and a second doseor cycle of treatment is an oral dose). In some embodiments, the firstand second dose or cycle of treatment include the same compound. In someembodiments, the first dose or cycle of treatment includes a firstcompound (e.g., a first compound described herein such asallopregnanolone) and the second dose or cycle of treatment includes asecond compound that is different from the first compound.

In some embodiments, the subject is substantially relieved of at leastone symptom within 3, 2, 1 days; 24, 20, 16, 12, 10, 8 hours or less ofsaid administration. In some embodiments, the subject is substantiallyrelieved of at least one symptom for 1, 2, 3, 4, 5, 6, or 7 days; 1, 2,3, or 4 weeks; or 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 months or more.

In some embodiments, the neuroactive steroid is selected frompregnanolone, ganaxolone, alphadalone, alphaxalone, andallopregnanolone. In some embodiments, the neuroactive steroid isdeuterated allopregnanolone. In some embodiments, the neuroactivesteroid is an estrol. In some embodiments, the neuroactive steroid is:

In some embodiments, the pharmaceutical composition is brexanolone.

In some embodiments, the neuroactive steroid is Compound 9 as describedherein.

In some embodiments, when the neuroactive steroid is allopregnanolone,then the neuroactive steroid or pharmaceutical composition comprisingthe neuroactive steroid (e.g., brexanolone) is administeredparenterally, wherein administering occurs through an intravenousintermittent infusion. In some embodiments, when the neuroactive steroidis Compound 9, then the neuroactive steroid or pharmaceuticalcomposition comprising the neuroactive steroid is administered orally.In some embodiments, the neuroactive steroid or pharmaceuticalcomposition comprising the neuroactive steroid is administeredchronically. In some embodiments, the neuroactive steroid orpharmaceutical composition comprising the neuroactive steroid isadministered acutely.

In some embodiments, the neuroactive steroid or pharmaceuticallyacceptable salt thereof or pharmaceutical composition comprising aneuroactive steroid is administered to the subject within 3 days, 2days, 1 day, or 24 hours of delivery of a baby (e.g., within 12 hours,within 6 hours, within 3 hours, within 2 hours, within 1 hour, within 30minutes).

In some embodiments, the subject is identified to be at risk through ascreening method (e.g., Edinburgh Postnatal Depression Scale (EPDS),e.g., a score of 10 or more on the EPDS, a score of 13 or more on theEPDS). In some embodiments, the subject is identified to be at riskthrough screening instruments such as Patient Health Questionnaire (PHQ)in various forms or the Hospital Anxiety and Depression Scales orGeriatric Depression Scale.

In some embodiments, the subject has given birth. In some embodiments,the subject has given birth within 3, 2, or 1 days; 24, 20, 16, 12, 8,6, 4, 3, 2, or 1 hours; or 60, 45, 30, 15, 10, or 5 minutes. In someembodiments, the subject is due to give birth. In some embodiments, thesubject is due to give birth in 9, 8, 7, 6, 5, 4, 3, 2, or 1 months; 4,3, 2, or 1 weeks; or 7, 6, 5, 4, 3, 2, or 1 days.

In some embodiments, the subject has an attribute, characteristic, orexposure (that increases the likelihood of developing a disorder asdescribed herein, e.g., neuroactive steroid deficiency). In someembodiments, the subject has a chronic illness (e.g., cancer orcardiovascular disease), other mental health disorders (includingsubstance misuse), or a family history of psychiatric disorders. In someembodiments, the subject is disabled or has poor health status due tomedical illness, complicated grief, chronic sleep disturbance,loneliness, or history of depression. In some embodiments, the subjecthas poor self-esteem, child-care stress, prenatal anxiety, life stress,decreased social support, single/unpartnered relationship status,history of depression, difficult infant temperament, previous postpartumdepression, lower socioeconomic status, or unintended pregnancy. In someembodiments, the subject has hyperemesis gravidarum (e.g., severe formof morning sickness, e.g., preventing adequate intake of food andfluids). In some embodiments, the subject has had a complication inpregnancy (e.g., emergency C-sections, pre-eclampsia, hospitalizationduring pregnancy, concern about fetal distress and admission of the babyto special care (NICU), the baby was in the NICU). In some embodiments,the subject has had emotionally painful or stressful experiences aroundpregnancy, childbirth, or early parenting (e.g., the subject was treatedfor infertility, had a previous miscarriage or other pregnancy loss,delivery of muliples, special needs, colic or difficult temperamentbaby, had difficulty feeding). In some embodiments, the subject has hada history of domestic violence, sexual or other abuse (e.g., abused as achild or as an adult). In some embodiments, the subject has had atraumatic childhood (e.g., loss of a parent, troubling relationship withparent). In some embodiments, the subject has stress (e.g., loss ofsomeone close, job loss, financial hardship, divorce, strain in arelationship, house move). In some embodiments, the subject has lack ofsocial support. In some embodiments, the subject has a perfectionist orcontrolling personality. In some embodiments, the subject is a female.In some embodiments, the female is not breast feeding. In someembodiments, the subject is an adult. In some embodiments, the subjectis from 18 to 45 years of age. In some embodiments, the subject issuffering from (e.g., has been diagnosed with) postpartum depression(e.g., severe postpartum depression). In some embodiments, the subjecthas experienced a Major Depressive Episode in the postpartum period. Insome embodiments, the period begins within the first 4 weeks followingdelivery of a baby.

In an aspect, provided is a method of treating a human subject sufferingfrom tremor, the method comprising administering a therapeuticallyeffective amount of a neuroactive steroid. In some embodiments, themethod does not result in sedation. In some embodiments, the tremor isessential tremor.

In some embodiments, the administering is performed parenterally. Insome embodiments, the administering is performed intravenously.

In some embodiments, the administering is performed orally.

In some embodiments, the administering comprises administering one ormore cycles of treatment, a cycle of treatment comprising: administeringa first dose of the neuroactive steroid; administering a second dose ofthe neuroactive steroid; and administering a third dose of theneuroactive steroid, said neuroactive steroid doses being sufficient totreat said subject.

In some embodiments, the first dose is 20 to 40 μg/kg/hr (e.g., about 30μg/kg/hr, 29 μg/kg/hr). In some embodiments, the second dose is 45 to 65μg/kg/hr (e.g., about 60 μg/kg/hr, 58 μg/kg/hr). In some embodiments,the third dose is 80 to 100 μg/kg/hr (e.g., about 90 μg/kg/hr, 86μg/kg/hr). In some embodiments, each of the first, second, and thirddoses are 2 to 6 hours (e.g., 4 hours) in duration. In some embodiments,each of the first, second, and third doses are 1, 2, 3, 4, 5, or 6 hoursin duration. In some embodiments, each of the first, second, and thirddoses are administered for equal periods of duration.

In some embodiments, the administering comprises administering twocycles of treatment.

In some embodiments, a rest period follows (e.g., immediately follows,is less than 60, 30, 20, 10, 5, 2, or 1 minute after) the first cycle oftreatment. In some embodiments, a rest period precedes the second cycleof treatment. In some embodiments, a rest period follows the first cycleof treatment and precedes the second cycle of treatment. In someembodiments, the rest period is 6 to 8 days (e.g., 7 days) in duration.

In some embodiments, the amount of neuroactive steroid delivered/unittime in the second dose, e.g., as measured in Kg/kg/hour, is 1 to 2times higher than that of the first dose. In some embodiments, theamount of neuroactive steroid delivered/unit time in the third dose,e.g., as measured in Kg/kg/hour, is 2 to 4 times higher than that of thefirst dose.

In some embodiments, said first dose results in a plasma concentrationof 10 to 100 nM, 25 to 75 nM, 40 to 60, or 50 nM. In some embodiments,said second dose results in a plasma concentration of 20 to 200 nM, 50to 150 nM, 80 to 120, or 100 nM. In some embodiments, said third doseresults in a plasma concentration of 30 to 300 nM, 100 to 200 nM, 120 to180, or 150 nM. In some embodiments, said first dose results in a plasmaconcentration of 50+/−10 nM, 50+/−5 nM, 50+/−2 nM, or 50 nM. In someembodiments, said second dose results in a plasma concentration of100+/−20 nM, 100+/−10 nM, 100+/−5 nM, or 100 nM. In some embodiments,said third dose results in a plasma concentration of 150+/−30 nM,150+/−20 nM, 150+/−10 nM, or 150 nM. In some embodiments, said firstdose is administered over a period of time that is not longer than 6, 5,4, or 3 hours. In some embodiments, said first dose is administered overa period of time that is at least 2, 3, or 4 hours in duration. In someembodiments, administration of the second dose occurs immediately afteradministration of the first dose. In some embodiments, administration ofthe third dose occurs immediately after administration of the seconddose.

In some embodiments, the duration of administration is at least 12, 24,48, 72, or 96 hours in duration. In some embodiments, the duration ofadministration is about 40, 50, 60, or 70 hours. In some embodiments,the administration is performed continuously.

In some embodiments, the administering comprises administering one ormore cycles of treatment, a cycle of treatment comprising: providing asingle infusion of the neuroactive steroid.

In some embodiments, the administering comprises administering one ormore cycles of treatment, a cycle of treatment comprising: administeringa first infusion of the neuroactive steroid; and administering a secondinfusion of the neuroactive steroid; said neuroactive steroid infusionsbeing sufficient to treat said subject.

In some embodiments, the administration of the second infusion occursimmediately after administration of the first infusion. In someembodiments, the amount of neuroactive steroid delivered/unit time inthe second infusion, e.g., as measured in Kg/kg/hour, is higher thanthat of the first infusion. In some embodiments, the amount ofneuroactive steroid delivered/unit time in the second infusion, e.g., asmeasured in Kg/kg/hour, is at least 1 to 2 times higher than that of thefirst infusion. In some embodiments, the amount of neuroactive steroiddelivered/unit time in the second infusion, e.g., as measured inKg/kg/hour, is lower than that of the first infusion. In someembodiments, the amount of neuroactive steroid delivered/unit time inthe second infusion, e.g., as measured in Kg/kg/hour, is at least 1 to 2times lower than that of the first infusion.

In some embodiments, the method comprises administering a plurality ofinfusions. In some embodiments, the method comprises administering afirst and second infusion. In some embodiments, the administration ofthe second infusion begins no longer than 90, 60, 30, 10, or 5 minutesafter the beginning or end of the administration of the first infusion.In some embodiments, the second infusion begins 0 to 90, 0 to 60, 0 to30, 0 to 10, or 0 to 5 minutes after the beginning or end of theadministration of the first infusion. In some embodiments, the secondinfusion begins no more than 60, 30, 20, 10, 5, 4, 3, 2, or 1 minute(s)after the end of administration of the first infusion. In someembodiments, the second infusion begins at the end of administration ofthe first infusion. In some embodiments, the first infusion and theinitiation of the second infusion are performed with the same deliverydevice, e.g., with the same cannula or reservoir. In some embodiments,the amount of neuroactive steroid delivered/unit time varies during thefirst infusion.

In some embodiments, the first (step-up) infusion delivers a smalleramount of neuroactive steroid/unit time than the second (maintenance)infusion. In some embodiments, the first (step-up) infusion comprisesadministering a plurality of step doses, wherein each subsequent stepdose delivers a larger amount of neuroactive steroid/unit time than thestep dose that precedes it.

In some embodiments, the amount of neuroactive steroid delivered/unittime varies during the second (step-down) infusion. In some embodiments,the second (step-down) infusion delivers a smaller amount of neuroactivesteroid/unit time than the first (maintenance) infusion. In someembodiments, the second (step-down) infusion comprises administering aplurality of step doses, wherein each subsequent step dose delivers asmaller amount of neuroactive steroid/unit time than the step dose thatprecedes it.

In some embodiments, the subject is 35 to 75 years of age. In someembodiments, the subject has a TETRAS Performance Subscale score of 2 orgreater for at least one maneuver selected from forward horizontal reachposture, lateral “wing beating” posture, or finger-nose-finger testing;in the ‘upper limb tremor’ test.

In some embodiments, the method provides acute treatment of the tremor(e.g., provides relief from a symptom in less than 1 week (e.g., within6 days, 5 days, 4 days, 3 days, 2 days, 1 day, or 12 hours).

In some embodiments, the method provides rapid onset of efficacy (e.g.,rapid reduction in a symptom of tremor; rapidly affective to reduce asymptom of tremor, e.g., a subject experiences relief from a symptom ofa tremor within 1 week (e.g., within 6 days, 5 days, 4 days, 3 days, 2days, 1 day, or 12 hours)).

In some embodiments, the therapeutic effect is sustained (e.g.,effectively treats a symptom of tremor and the efficacy is maintainedfor at least 1 day (e.g., at least 2 days, 3 days, 4 days, 5 days, 6days, 1 week, 2 weeks, 3 weeks, 1 month, 2 months, 3 months, 4 months, 5months, or 6 months).

In some embodiments, the efficacy is maintained after a single course oftreatment (e.g., single dose, multiple doses, or cycle of treatment) ofa compound described herein (e.g., allopregnanolone).

In some embodiments, the therapeutic effect is does not cause an adverseevent (e.g., does not cause a severe or moderate adverse event, e.g.,during treatment or 3 days, 7 days, 10 days, 20 days, 30 days, 60 days,90 days, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9months, 10 months, 11 months, 12 months, or more after treatment).

In some embodiments, the method includes a course of treatment withmultiple dosages or cycles of treatment (e.g., a first dose or cycle oftreatment is a parenteral dose such as an i.v. dose, and a second doseor cycle of treatment is an oral dose).

In some embodiments, the first and second dose or cycle of treatmentinclude the same compound. In some embodiments, the first dose or cycleof treatment includes a first compound (e.g., a first compound describedherein such as allopregnanolone) and the second dose or cycle oftreatment includes a second compound that is different from the firstcompound.

In some embodiments, the subject has been diagnosed with essentialtremor. In some embodiments, the subject has suffered from tremor for atleast 2 years.

In an aspect, provided is a method of treating a subject suffering fromtremor (e.g., essential tremor), comprising: administering a first dose,wherein administration of said first dose; and results in a plasma levelof neuroactive steroid of 50 to 300 nM neuroactive steroid; a restperiod comprising at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 days; andadministering a second dose, wherein administration of said second dose;and results in a plasma level of neuroactive steroid of 50 to 300 nMneuroactive steroid; wherein, collectively, the administrations areprovided in sufficient amount to treat said subject. In someembodiments, the method does not result in sedation.

In an aspect, provided is a method of treating a subject suffering fromtremor (e.g., essential tremor), comprising: administering a first dose,wherein administration of said first dose lasts for at least 1 day; andresults in a plasma level of neuroactive steroid of 100 to 200 nMneuroactive steroid; a rest period comprising at least 5, 6, or 7 days;and administering a second dose, wherein administration of said seconddose lasts for at least 1 day; and results in a plasma level ofneuroactive steroid of 100 to 200 nM neuroactive steroid; wherein,collectively, the administrations are provided in sufficient amount totreat said subject. In some embodiments, the method does not result insedation.

In an aspect, provided is a method of treating a subject suffering fromtremor (e.g., essential tremor), comprising: administering a first dose,wherein administration of said first dose lasts for 1 day; and resultsin a plasma level of neuroactive steroid of 150 nM neuroactive steroid;a rest period comprising 7 days; and administering a second dose,wherein administration of said second dose lasts for 1 day; and resultsin a plasma level of neuroactive steroid of 150 nM neuroactive steroid;wherein, collectively, the administrations are provided in sufficientamount to treat said subject. In some embodiments, the method does notresult in sedation.

In some embodiments, the administration of the second dose begins nolonger than 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 days after thebeginning or end of the administration of the first dose. In someembodiments, the second dose begins 1 to 14, 3 to 12, 5 to 10, or 7 daysafter the beginning or end of the administration of the first dose. Insome embodiments, the second dose begins no more than 14, 12, 10, 9, 8,7, 6, 5, 3, 2, or 1 day after the end of administration of the firstdose. In some embodiments, the first dose and the initiation of thesecond dose are performed with the same delivery device, e.g., with thesame cannula or reservoir. In some embodiments, the plasma concentrationof said third dose is measured at a preselected time, e.g., at 10, 15,20, 30, 45, or 60 minutes, 2, 3, 4, 5, 6, 8, 10, 12, or 24 hours, or 2,3, or 4 days after the initiation of said third dose. In someembodiments, said third dose results in a plasma concentration of 150nM, e.g., as measured at a preselected time, e.g., at 10, 15, 20, 30,45, or 60 minutes, 2, 3, 4, 5, 6, 8, 10, 12, or 24 hours, or 2, 3, or 4days after the initiation of said third dose.

In an aspect, provided is a method of treating a subject suffering fromtremor (e.g., essential tremor) comprising the steps of: a) receivinginformation related to the therapeutic effect of a neuroactive steroid(e.g., allopregnanolone or Compound 9) in reducing tremor (e.g.,symptoms of tremor) in a subject treated with the neuroactive steroid(e.g., allopregnanolone or Compound 9); and b) administering to thesubject a therapeutic agent (e.g., neuroactive steroid) if theinformation indicates that tremor (e.g., symptoms of tremor) is reducedin the subject as compared to the subject before having received theneuroactive steroid (e.g., allopregnanolone or Compound 9), therebytreating the subject.

In an aspect, provided is a method of selecting a therapeutic agent(e.g., a neuroactive steroid) for treating tremor (e.g., essentialtremor) in a human subject treated with a neuroactive steroid (e.g.,allopregnanolone or Compound 9) comprising the steps of: a) receivinginformation related to the therapeutic effect of a neuroactive steroid(e.g., allopregnanolone or Compound 9) in reducing tremor (e.g.,symptoms of tremor) in a subject; and b) selecting the therapeutic agent(e.g., neuroactive steroid) if the information indicates that tremor(e.g., symptoms of the depression or anxiety disorder) is reduced in thesubject as compared to the subject before having received theneuroactive steroid (e.g., allopregnanolone or Compound 9).

In an aspect, provided is a method of evaluating (e.g., diagnosing,prognosing, and determining a course of treatment in) a subjectsuffering from tremor (e.g., essential tremor), comprising the steps of:a) receiving information related to the therapeutic effect of aneuroactive steroid (e.g., allopregnanolone) in reducing tremor (e.g.,symptoms of tremor) in a subject treated with the neuroactive steroid(e.g., allopregnanolone); and b) determining if tremor (e.g., symptomsof tremor) is reduced in the subject as compared to the subject beforereceiving the neuroactive steroid (e.g., allopregnanolone), therebyevaluating the subject.

In some embodiments, the information is received, e.g., about 1, 2, 3,4, 5, or 6 days; about 1, 2, or 3 weeks; about 1, 2, or 3 months afteradministration of the neuroactive steroid (e.g., allopregnanolone).

In some embodiments, the subject has been administered the neuroactivesteroid less than about 3 months (e.g., less than about 2 or 1 month; 3,2, or 1 weeks; 6, 5, 4, 3, 2, or 1 days) prior to receiving theinformation. In some embodiments, the subject has been administered theneuroactive steroid (e.g., allopregnanolone) by intravenous infusion.

In some embodiments, the therapeutic agent is administered by oraladministration. In some embodiments, the therapeutic agent isadministered as a solid composition (e.g., a solid dosage form).

In an aspect, provided is a method of evaluating (e.g., diagnosing,prognosing, or determining a course of treatment in) a subject sufferingfrom tremor (e.g., essential tremor), comprising the steps of: a)administering to the subject a therapeutic agent (e.g., neuroactivesteroid); and b) receiving information related to the therapeutic effectof a neuroactive steroid (e.g., allopregnanolone) in reducing tremor(e.g., symptoms of tremor) in a subject treated with the neuroactivesteroid (e.g., allopregnanolone), thereby evaluating the subject. Insome embodiments, the information is acquired by imaging the subject ora sample from the subject. In some embodiments, the information isacquired by fMRI. In some embodiments, the information is acquired bySPECT.

In an aspect, provided is a method for treating a human subjectsuffering from depression (e.g., postpartum depression) or an anxietydisorder, the method comprising: administering a first infusion of aneuroactive steroid, wherein said first/step-up infusion is administeredfor 8-16 hours (e.g., 12 hours); administering a second/maintenanceinfusion of a neuroactive steroid, wherein said second/maintenanceinfusion is administered for 24-48 hours (e.g., 36 hours); andadministering a third infusion of a neuroactive steroid, wherein saidthird/downward taper infusion is administered for 8-16 hours (e.g., 12hours); said neuroactive steroid doses being sufficient to treat saidsubject.

In some embodiments, the subject is identified to be at risk through ascreening method (e.g., Edinburgh Postnatal Depression Scale (EPDS),e.g., a score of 10 or more on the EPDS, a score of 13 or more on theEPDS). In some embodiments, the subject is identified to be at riskthrough screening instruments such as Patient Health Questionnaire (PHQ)in various forms or the Hospital Anxiety and Depression Scales orGeriatric Depression Scale.

In some embodiments, the subject has given birth. In some embodiments,the subject has given birth within 3, 2, 1 days; 24, 20, 16, 12, 8, 6,4, 3, 2, 1 hours; 60, 45, 30, 15, 10, 5 minutes. In some embodiments,the subject is due to give birth. In some embodiments, the subject isdue to give birth in 9, 8, 7, 6, 5, 4, 3, 2, 1 months; 4, 3, 2, 1 weeks;7, 6, 5, 4, 3, 2, 1 days.

In some embodiments, the subject has an attribute, characteristic, orexposure (that increases the likelihood of developing a disorder asdescribed herein, e.g., neuroactive steroid deficiency). In someembodiments, the subject has a chronic illness (e.g., cancer orcardiovascular disease), other mental health disorders (includingsubstance misuse), or a family history of psychiatric disorders. In someembodiments, the subject is disabled or has poor health status due tomedical illness, complicated grief, chronic sleep disturbance,loneliness, or history of depression. In some embodiments, the subjecthas poor self-esteem, child-care stress, prenatal anxiety, life stress,decreased social support, single/unpartnered relationship status,history of depression, difficult infant temperament, previous postpartumdepression, lower socioeconomic status, or unintended pregnancy.

In some embodiments, the subject has hyperemesis gravidarum (e.g.,severe form of morning sickness, e.g., preventing adequate intake offood and fluids). In some embodiments, the subject has had acomplication in pregnancy (e.g., emergency C-sections, pre-eclampsia,hospitalization during pregnancy, concern about fetal distress andadmission of the baby to special care (NICU), the baby was in the NICU).In some embodiments, the subject has had emotionally painful orstressful experiences around pregnancy, childbirth, or early parenting(e.g., the subject was treated for infertility, had a previousmiscarriage or other pregnancy loss, delivery of muliples, specialneeds, colic or difficult temperament baby, had difficulty feeding). Insome embodiments, the subject has had a history of domestic violence,sexual or other abuse (e.g., abused as a child or as an adult). In someembodiments, the subject has had a traumatic childhood (e.g., loss of aparent, troubling relationship with parent). In some embodiments, thesubject has stress (e.g., loss of someone close, job loss, financialhardship, divorce, strain in a relationship, house move). In someembodiments, the subject has lack of social support. In someembodiments, the subject has a perfectionist or controlling personality.

In an aspect, provided is a method for treating a human subjectsuffering from depression (e.g., postpartum depression or majordepressive disorder) or an anxiety disorder, the method comprising:administering a first infusion of a neuroactive steroid, saidfirst/step-up infusion comprising administering a continuouslyincreasing amount of neuroactive steroid at an amount of neuroactivesteroid/unit time of 5-100 Kg/kg/hour, 10-80 μg/kg/hour, 15-70μg/kg/hour, or 30 μg/kg/hour; administering a second/maintenanceinfusion of a neuroactive steroid, said second/maintenance infusioncomprising administering an amount of neuroactive steroid/unit time of50-100 Kg/kg/hour, 70-100 μg/kg/hour, 86 μg/kg/hour, or 60 Kg/kg/hour;and administering a third infusion of a neuroactive steroid, saidthird/downward taper infusion comprising administering a continuouslydecreasing amount of neuroactive steroid at an amount of neuroactivesteroid/unit time of 5-100 μg/kg/hour, 10-80 μg/kg/hour, 15-70Kg/kg/hour, or 90 Kg/kg/hour; said neuroactive steroid doses beingsufficient to treat said subject.

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Hamilton Depression Score (HAM-D)) within 4, 3,2, or 1 days; or 24, 20, 16, 12, 10, or 8 hours or less. In someembodiments, the therapeutic effect is a decrease from baseline in HAM-Dscore at the end of a treatment period (e.g., 12, 24, or 48 hours afteradministration; or 24, 48, 60, 72, or 96 hours or more).

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Edinburgh Postnatal Depression Scale (EPDS))within 4, 3, 2, or 1 days; or 24, 20, 16, 12, 10, or 8 hours or less. Insome embodiments, the therapeutic effect is a improvement measured bythe EPDS.

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Clinical Global Impression-Improvement Scale(CGI)) within 4, 3, 2, 1 days; 24, 20, 16, 12, 10, 8 hours or less. Insome embodiments, the therapeutic effect is a CGI score of 2 or less.

In some embodiments, the subject is identified to be at risk through ascreening method (e.g., Edinburgh Postnatal Depression Scale (EPDS),e.g., a score of 10 or more on the EPDS, a score of 13 or more on theEPDS). In some embodiments, the subject is identified to be at riskthrough screening instruments such as Patient Health Questionnaire (PHQ)in various forms or the Hospital Anxiety and Depression Scales orGeriatric Depression Scale.

In some embodiments, the subject has given birth (e.g., a live birth,stillbirth, miscarriage). In some embodiments, the subject has givenbirth within 3, 2, 1 days; 24, 20, 16, 12, 8, 6, 4, 3, 2, 1 hours; 60,45, 30, 15, 10, 5 minutes. In some embodiments, the subject is due togive birth. In some embodiments, the subject is in her third trimesterof pregnancy. In some embodiments, the subject has reached termpregnancy (e.g., early term (i.e., between 37 weeks and 38 weeks and 6days); full term (i.e., between 39 weeks and 40 weeks and 6 days); lateterm (i.e., between 41 weeks and 41 weeks and 6 days); or postterm(i.e., 42 weeks and beyond)) or has given early term, full term, lateterm, or postterm birth. In some embodiments, the subject is due to givebirth in 9, 8, 7, 6, 5, 4, 3, 2, 1 months; 4, 3, 2, 1 weeks; 7, 6, 5, 4,3, 2, 1 days. In some embodiments, the subject has terminated herpregnancy. In some embodiments, the subject has had an abortion.

In some embodiments, the subject has an attribute, characteristic, orexposure (that increases the likelihood of developing a disorder asdescribed herein, e.g., neuroactive steroid deficiency). In someembodiments, the subject has a chronic illness (e.g., cancer orcardiovascular disease), other mental health disorders (includingsubstance misuse), or a family history of psychiatric disorders. In someembodiments, the subject is disabled or has poor health status due tomedical illness, complicated grief, chronic sleep disturbance,loneliness, or history of depression. In some embodiments, the subjecthas poor self-esteem, child-care stress, prenatal anxiety, life stress,decreased social support, single/unpartnered relationship status,history of depression, difficult infant temperament, previous postpartumdepression, lower socioeconomic status, or unintended pregnancy.

In some embodiments, the subject has hyperemesis gravidarum (e.g.,severe form of morning sickness, e.g., preventing adequate intake offood and fluids). In some embodiments, the subject has had acomplication in pregnancy (e.g., emergency C-sections, pre-eclampsia,hospitalization during pregnancy, concern about fetal distress andadmission of the baby to special care (NICU), the baby was in the NICU).In some embodiments, the subject has had emotionally painful orstressful experiences around pregnancy, childbirth, or early parenting(e.g., the subject was treated for infertility, had a previousmiscarriage or other pregnancy loss, delivery of muliples, specialneeds, colic or difficult temperament baby, had difficulty feeding). Insome embodiments, the subject has had a history of domestic violence,sexual or other abuse (e.g., abused as a child or as an adult). In someembodiments, the subject has had a traumatic childhood (e.g., loss of aparent, troubling relationship with parent). In some embodiments, thesubject has stress (e.g., loss of someone close, job loss, financialhardship, divorce, strain in a relationship, house move). In someembodiments, the subject has lack of social support. In someembodiments, the subject has a perfectionist or controlling personality.

In an aspect, provided is a method of treating a subject suffering fromdepression or an anxiety disorder comprising the steps of: a) receivinginformation related to the therapeutic effect of a neuroactive steroid(e.g., allopregnanolone or Compound 9) in reducing the depression oranxiety disorder (e.g., symptoms of the depression or anxiety disorder)in a subject treated with the neuroactive steroid (e.g.,allopregnanolone or Compound 9); and b) administering to the subject atherapeutic agent (e.g., a neuroactive steroid) if the informationindicates that the depression or anxiety disorder (e.g., symptoms of thedepression or anxiety disorder) is reduced in the subject as compared tothe subject before having received the neuroactive steroid (e.g.,allopregnanolone or Compound 9), thereby treating the subject. In someembodiments, the depression is major depressive disorder. In someembodiments, the depression is postpartum depression.

In an aspect, provided is a method of selecting a therapeutic agent(e.g., a neuroactive steroid) for treating depression or an anxietydisorder in a human subject treated with a neuroactive steroid (e.g.,allopregnanolone or Compound 9) comprising the steps of: a) receivinginformation related to the therapeutic effect of a neuroactive steroid(e.g., allopregnanolone or Compound 9) in reducing the depression oranxiety disorder (e.g., symptoms of the depression or anxiety disorder)in a subject; and b) selecting the therapeutic agent (e.g., neuroactivesteroid) if the information indicates that the depression or anxietydisorder (e.g., symptoms of the depression or anxiety disorder) isreduced in the subject as compared to the subject before having receivedthe neuroactive steroid (e.g., allopregnanolone or Compound 9). In someembodiments, the depression is major depressive disorder. In someembodiments, the depression is postpartum depression.

In an aspect, provided is a method of evaluating (e.g., diagnosing,prognosing, and determining a course of treatment in) a subjectsuffering from depression or anxiety disorder, comprising the steps of:

-   -   a) receiving information related to the therapeutic effect of a        neuroactive steroid (e.g., allopregnanolone or Compound 9) in        reducing depression or anxiety disorder (e.g., symptoms of the        depression or anxiety disorder) in a subject treated with the        neuroactive steroid (e.g., allopregnanolone or Compound 9);        and b) determining if the depression or anxiety disorder (e.g.,        symptoms of the depression or anxiety disorder) is reduced in        the subject as compared to the subject before receiving the        neuroactive steroid (e.g., allopregnanolone), thereby evaluating        the subject. In some embodiments, the information is received,        e.g., about 1, 2, 3, 4, 5, or 6 days; about 1, 2, or 3 weeks;        about 1, 2, or 3 months after administration of the neuroactive        steroid (e.g., allopregnanolone). In some embodiments, the        subject has been administered the neuroactive steroid less than        about 3 months (e.g., less than about 2 or 1 month; 3, 2, or 1        weeks; 6, 5, 4, 3, 2, or 1 days) prior to receiving the        information. In some embodiments, the subject has been        administered the neuroactive steroid (e.g., allopregnanolone) by        intravenous infusion. In some embodiments, the therapeutic agent        is administered by oral administration. In some embodiments, the        therapeutic agent is administered as a solid composition (e.g.,        a solid dosage form).

In an aspect, provided is a method of evaluating (e.g., diagnosing,prognosing, or determining a course of treatment in) a subject sufferingfrom depression or anxiety disorder, comprising the steps of:

-   -   a) administering to the subject a therapeutic agent (e.g.,        neuroactive steroid or Compound 9); and b) receiving information        related to the therapeutic effect of a neuroactive steroid        (e.g., allopregnanolone or Compound 9) in reducing the        depression or anxiety disorder (e.g., symptoms of the depression        or anxiety disorder) in a subject treated with the neuroactive        steroid (e.g., allopregnanolone or Compound 9), thereby        evaluating the subject. In some embodiments, the information is        acquired by imaging the subject or a sample from the subject. In        some embodiments, the information is acquired by fMRI. In some        embodiments, the information is acquired by SPECT.

In an aspect, provided is a method of treating a subject suffering froma neuroendocrine disease (or neuroendocrine dysfunction), comprising:intravenously administering to the subject a therapeutically effectiveamount of a neuroactive steroid (e.g., allopregnanolone), whereinadministering occurs by continuous intravenous infusion or intermittentintravenous infusion. In some embodiments, the concentrations ofallopregnanolone in plasma is greater than that in a normal subject. Insome embodiments, the concentrations of allopregnanolone in plasma is 10nM in plasma or less.

In an aspect, provided is a method of treating a symptom of aneuroendocrine diseases (or neuroendocrine dysfunction), comprising:intravenously administering to the subject a therapeutically effectiveamount of a neuroactive steroid (e.g., allopregnanolone), whereinadministering occurs by continuous intravenous infusion. In someembodiments, the symptom is reduced at a magnitude or rate differentfrom that observed in a subject without having received treatment.

In an aspect, provided is a method of increasing allopregnanolone levelsin a subject (e.g., a subject with low levels of allopregnanolone ascompared with a subject with normal levels of allopregnanolone),comprising: intravenously administering to the subject a therapeuticallyeffective amount of a neuroactive steroid (e.g., allopregnanolone),wherein administering occurs by continuous intravenous infusion orintermittent infusion.

In one aspect, provided herein are methods for treating a disease ordisorder described herein, comprising administering to a subject atherapeutically effective amount of Compound 9

or pharmaceutically acceptable salt or isotopologue thereof.

In an aspect, provided is a method for treating or preventing a disorderdescribed herein, comprising orally administering a total daily dose ofCompound 9, or pharmaceutically acceptable salt or isotopologue thereof,or pharmaceutical composition thereof of about 10 mg to about 100 mg toa subject in need thereof.

In some embodiments, Compound 9, or a pharmaceutically acceptable saltor isotopologue thereof, or pharmaceutical composition thereof isadministered chronically. In some embodiments, Compound 9, orpharmaceutically acceptable salt or isotopologue thereof, orpharmaceutical composition thereof is administered acutely.

In some embodiments, the disease or disorder is a GABA-related diseaseor disorder. In some embodiments, the GABA receptor is modulated (e.g.,as determined by assessment of electrical activity in the brain using anelectroencephalogram (EEG)). In some embodiments, the GABA receptor ismodulated (e.g., as determined by assessment of electrical activity inthe brain by beta-band EEG).

In some embodiments, the subject is administered about 10 mg to about 80mg (e.g., about 10 mg to about 60 mg) of the compound. In someembodiments, the subject is administered about 10 mg to about 50 mg(e.g., about 35 mg) of the compound. In some embodiments, the subject isadministered less than about 100 mg, less than about 80 mg, less thanabout 60 mg, less than about 50, less than about 40, less than about 20mg.

In some embodiments, the subject is administered at least once a day. Insome embodiments, the subject is administered once a day.

In some embodiments, the subject is administered for at least 1, 2, 3,4, 5, 6, 7 days. In some embodiments, the subject is administered for 1,2, 3, 4, 5, 6, 7 days.

In some embodiments, the subject has not had food for 1, 2, 4, 6, 8, 12,24 hours. In some embodiments, the subject has had food within 1, 2, 4,6, 8, 12, 24 hours of administration.

In some embodiments, the subject is administered as a pharmaceuticalcomposition. In some embodiments, the subject is administered a solutionformulation. In some embodiments, the subject is administered asuspension formulation. In some embodiments, the subject is administereda solid dosage formulation.

In some embodiments, the composition comprises a cyclodextrin (e.g.,sulfoalkyl ether β-cyclodextrin (SAEBCD) or hydroxypropyl β-cyclodextrin(HPBCD)).

In some embodiments, the disorder is a seizure or epilepsy disorder(e.g., orphan epilepsies (e.g., Dravet syndrome, Lennox-Gastautsyndrome, Tuberous sclerosis complex, Rett syndrome, PCDH19 epilepsy),seizure associated with a neurological disorder).

In some embodiments, the disorder is depression (e.g., postpartumdepression).

In some embodiments, the subject does not experience an adverse effect(e.g., a serious adverse event or severe adverse event as describedherein). In some embodiments, the subject does not experience anincrease from pre-dose supine blood pressure (e.g., systolic, diastolic)1, 2, 4, 8, 12, 24 hours or more after administration. In someembodiments, the subject does not experience an increase in heart ratefrom 1, 2, 4, 8, 12, 24 hours or more after administration. In someembodiments, the subject experiences sedation (e.g., mild, transient,and associated with daily peak exposure). In some embodiments, thesubject does not experience sedation (e.g., rate of moderate to deepsedation as defined by a structured rating scale (e.g., MOAA/S) iscomparable to placebo (e.g., MOAA/S is less than 3, MOAA/S is less than2). In some embodiments, the subject is not sedated relative to areference standard. In some embodiments, the reference standard is theamount of sedation relative to a subject administered a placebo. In someembodiments, the subject does not experience sedation, as measured in ascore of 3 or less as measured by MOAA/S (e.g., as measured in a scoreof 2 or less as measured by MOAA/S. (e.g., rate of moderate to deepsedation as defined by a structured rating scale (e.g., MOAA/S) iscomparable to placebo (e.g., MOAA/S is 3 or less, MOAA/S is 2 or less).In some embodiments, the subject does not experience sedation e.g., asmeasured by a score of 5 or higher as measured by SSS. In someembodiments, the subject does not experience impact on cognition e.g.,as measured by testing of psychomotor function, attention, visuallearning, or executive function.

In some embodiments, the method further comprises administering anadditional therapeutic agent.

In an aspect, provided is a method for treating a human subject, themethod comprising: identifying a subject at risk of suffering fromdepression (e.g., postpartum depression) or an anxiety disorder; andadministering (e.g., orally, intraveneously) to the subject atherapeutically effective amount of Compound 9.

In some embodiments, the therapeutic agent is administered to thesubject within 3 days, 2 days, 1 day, 24 hours of delivery of a baby(e.g., within 12 hours, within 6 hours, within 3 hours, within 2 hours,within 1 hour, within 30 minutes). In some embodiments, Compound 9 or acomposition comprising Compound 9 is administered orally.

In some embodiments, the subject is identified to be at risk through ascreening method (e.g., Edinburgh Postnatal Depression Scale (EPDS),e.g., a score of 10 or more on the EPDS, a score of 13 or more on theEPDS). In some embodiments, the subject has given birth (e.g., thesubject has given birth within 3, 2, 1 days; 24, 20, 16, 12, 8, 6, 4, 3,2, 1 hours; 60, 45, 30, 15, 10, 5 minutes). In some embodiments, thesubject is due to give birth. In some embodiments, the subject is due togive birth in 9, 8, 7, 6, 5, 4, 3, 2, 1 months; 4, 3, 2, 1 weeks; 7, 6,5, 4, 3, 2, 1 days. In some embodiments, the subject has an attribute,characteristic, or exposure (that increases the likelihood of developinga disorder as described herein, e.g., neuroactive steroid deficiency).In some embodiments, the subject has hyperemesis gravidarum (e.g.,severe form of morning sickness, e.g., preventing adequate intake offood and fluids). In some embodiments, the subject has had acomplication in pregnancy (e.g., emergency C-sections, pre-eclampsia,hospitalization during pregnancy, concern about fetal distress andadmission of the baby to special care (NICU), the baby was in the NICU).In some embodiments, the subject has had emotionally painful orstressful experiences around pregnancy, childbirth, or early parenting(e.g., the subject was treated for infertility, had a previousmiscarriage or other pregnancy loss, delivery of muliples, specialneeds, colic or difficult temperament baby, had difficulty feeding). Insome embodiments, the subject has had a history of domestic violence,sexual or other abuse (e.g., abused as a child or as an adult). In someembodiments, the subject has had a traumatic childhood (e.g., loss of aparent, troubling relationship with parent). In some embodiments, thesubject has stress (e.g., loss of someone close, job loss, financialhardship, divorce, strain in a relationship, house move). In someembodiments, the subject has lack of social support. In someembodiments, the subject has a perfectionist or controlling personality.In some embodiments, the therapeutic agent is a Selective SerotoninReuptake Inhibitor (SSRI).

In an aspect, provided is a method for treating a human subjectsuffering from major depressive disorder (e.g., postpartum depression)or an anxiety disorder, the method comprising administering (e.g.,orally, intraveneously) to the subject a therapeutically effectiveamount of Compound 9.

In an aspect, provided is a method for treating a human subjectsuffering from depression (e.g., postpartum depression) or an anxietydisorder, the method comprising administering (e.g., orally,intraveneously) to the subject a therapeutically effective amount ofCompound 9.

In some embodiments, the depression is clinical depression (e.g., severedepression), postnatal or postpartum depression, atypical depression,melancholic depression, Psychotic Major Depression (PMD), catatonicdepression, Seasonal Affective Disorder (SAD), dysthymia, doubledepression, Depressive Personality Disorder (DPD), Recurrent BriefDepression (RBD), minor depressive disorder, bipolar disorder or manicdepressive disorder, post-traumatic stress disorders, depression causedby chronic medical conditions, treatment-resistant depression,refractory depression, suicidality, suicidal ideation, or suicidalbehavior. In some embodiments, the depression is severe depression. Insome embodiments, the depression is postpartum depression. In someembodiments, the depression is major depressive disorder.

In some embodiments, the method provides acute treatment of thedepression (e.g., within 72 hours, 48 hours, 24 hours, 12 hours, orless). In some embodiments, the method provides maintenance treatment orpreventative treatment. In some embodiments, the method provides acutetreatment of the depression or anxiety disorder (e.g., provides relieffrom a symptom in less than 1 week (e.g., within 6 days, 5 days, 4 days,3 days, 2 days, 1 day, or 12 hours). In some embodiments, the methodprovides rapid onset of efficacy (e.g., rapid reduction in a symptom ofdepression or anxiety disorder; rapidly affective to reduce a symptom ofdepression or anxiety disorder, e.g., a subject experiences relief froma symptom of depression or anxiety disorder described herein within 1week (e.g., within 6 days, 5 days, 4 days, 3 days, 2 days, 1 day, or 12hours)). In some embodiments, the therapeutic effect is sustained (e.g.,effectively treats a symptom of depression or anxiety disorder and theefficacy is maintained for at least 1 day (e.g., at least 2 days, 3days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 1 month, 2months, 3 months, 4 months, 5 months, or 6 months, 7 months, 8 months, 9months, 10 months, 11 months, 1 year, 2 years, or more). In someembodiments, the efficacy is maintained after a single course oftreatment (e.g., single dose, multiple doses, or cycle of treatment) ofCompound 9.

In some embodiments, the therapeutic effect is does not cause an adverseevent (e.g., does not cause a severe or moderate adverse event, e.g.,during treatment or 3 days, 7 days, 10 days, 20 days, 30 days, 60 days,90 days, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9months, 10 months, 11 months, 12 months, or more after treatment).

In some embodiments, the subject is substantially relieved of at leastone symptom within 3, 2, 1 days; 24, 20, 16, 12, 10, 8 hours or less ofsaid administration. In some embodiments, the subject is substantiallyrelieved of at least one symptom for 1, 2, 3, 4, 5, 6, 7 days; 1, 2, 3,4 weeks; 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 months or more.

In some embodiments, Compound 9 is administered to a pregnant subject.In some embodiments, the subject is pregnant. In some embodiments,Compound 9 is administered to the subject in a pregnant subject in thethird trimester of the pregnancy.

In some embodiments, Compound 9 is administered to the subject within 3days, 2 days, 1 day, 24 hours of delivery of a baby (e.g., within 12hours, within 6 hours, within 3 hours, within 2 hours, within 1 hour,within 30 minutes).

In some embodiments, the subject is identified to be at risk through ascreening method (e.g., Edinburgh Postnatal Depression Scale (EPDS),e.g., a score of 10 or more on the EPDS, a score of 13 or more on theEPDS). In some embodiments, the subject has given birth (e.g., thesubject has given birth within 3, 2, 1 days; 24, 20, 16, 12, 8, 6, 4, 3,2, 1 hours; 60, 45, 30, 15, 10, 5 minutes). In some embodiments, thesubject is due to give birth. In some embodiments, the subject is due togive birth in 9, 8, 7, 6, 5, 4, 3, 2, 1 months; 4, 3, 2, 1 weeks; 7, 6,5, 4, 3, 2, 1 days. In some embodiments, the subject has an attribute,characteristic, or exposure (that increases the likelihood of developinga disorder as described herein, e.g., neuroactive steroid deficiency).In some embodiments, the subject has hyperemesis gravidarum (e.g.,severe form of morning sickness, e.g., preventing adequate intake offood and fluids). In some embodiments, the subject has had acomplication in pregnancy (e.g., emergency C-sections, pre-eclampsia,hospitalization during pregnancy, concern about fetal distress andadmission of the baby to special care (NICU), the baby was in the NICU).In some embodiments, the subject has had emotionally painful orstressful experiences around pregnancy, childbirth, or early parenting(e.g., the subject was treated for infertility, had a previousmiscarriage or other pregnancy loss, delivery of muliples, specialneeds, colic or difficult temperament baby, had difficulty feeding) Insome embodiments, the subject has had a history of domestic violence,sexual or other abuse (e.g., abused as a child or as an adult). In someembodiments, the subject has had a traumatic childhood (e.g., loss of aparent, troubling relationship with parent). In some embodiments, thesubject has stress (e.g., loss of someone close, job loss, financialhardship, divorce, strain in a relationship, house move). In someembodiments, the subject has lack of social support. In someembodiments, the subject has a perfectionist or controlling personality.In some embodiments, the subject is a female. In some embodiments, thefemale is not breast feeding. In some embodiments, the subject is anadult. In some embodiments, the subject is from 18 to 45 years of age.In some embodiments, the subject is suffering from (e.g., has beendiagnosed with) postpartum depression (e.g., severe postpartumdepression). In some embodiments, the subject has experienced a MajorDepressive Episode in the postpartum period. In some embodiments, theperiod begins within the first 4 weeks following delivery of a baby.

Definitions Chemical Definitions

Definitions of specific functional groups and chemical terms aredescribed in more detail below. The chemical elements are identified inaccordance with the Periodic Table of the Elements, CAS version,Handbook of Chemistry and Physics, 75^(th) Ed., inside cover, andspecific functional groups are generally defined as described therein.Additionally, general principles of organic chemistry, as well asspecific functional moieties and reactivity, are described in ThomasSorrell, Organic Chemistry, University Science Books, Sausalito, 1999;Smith and March, March's Advanced Organic Chemistry, 5^(th) Edition,John Wiley & Sons, Inc., New York, 2001; Larock, Comprehensive OrganicTransformations, VCH Publishers, Inc., New York, 1989; and Carruthers,Some Modern Methods of Organic Synthesis, 3^(rd) Edition, CambridgeUniversity Press, Cambridge, 1987.

Compounds described herein can comprise one or more asymmetric centers,and thus can exist in various isomeric forms, e.g., enantiomers and/ordiastereomers. For example, the compounds described herein can be in theform of an individual enantiomer, diastereomer or geometric isomer, orcan be in the form of a mixture of stereoisomers, including racemicmixtures and mixtures enriched in one or more stereoisomer. Isomers canbe isolated from mixtures by methods known to those skilled in the art,including chiral high pressure liquid chromatography (HPLC) and theformation and crystallization of chiral salts; or preferred isomers canbe prepared by asymmetric syntheses. See, for example, Jacques et al.,Enantiomers, Racemates and Resolutions (Wiley Interscience, New York,1981); Wilen et al., Tetrahedron 33:2725 (1977); Eliel, Stereochemistryof Carbon Compounds (McGraw-Hill, NY, 1962); and Wilen, Tables ofResolving Agents and Optical Resolutions p. 268 (E. L. Eliel, Ed., Univ.of Notre Dame Press, Notre Dame, IN 1972). The invention additionallyencompasses compounds described herein as individual isomerssubstantially free of other isomers, and alternatively, as mixtures ofvarious isomers.

As used herein a pure enantiomeric compound is substantially free fromother enantiomers or stereoisomers of the compound (i.e., inenantiomeric excess). In other words, an “S” form of the compound issubstantially free from the “R” form of the compound and is, thus, inenantiomeric excess of the “R” form. The term “enantiomerically pure” or“pure enantiomer” denotes that the compound comprises more than 75% byweight, more than 80% by weight, more than 85% by weight, more than 90%by weight, more than 91% by weight, more than 92% by weight, more than93% by weight, more than 94% by weight, more than 95% by weight, morethan 96% by weight, more than 97% by weight, more than 98% by weight,more than 98.5% by weight, more than 99% by weight, more than 99.2% byweight, more than 99.5% by weight, more than 99.6% by weight, more than99.7% by weight, more than 99.8% by weight or more than 99.9% by weight,of the enantiomer. In certain embodiments, the weights are based upontotal weight of all enantiomers or stereoisomers of the compound.

In the compositions provided herein, an enantiomerically pure compoundcan be present with other active or inactive ingredients. For example, apharmaceutical composition comprising enantiomerically pure R-compoundcan comprise, for example, about 90% excipient and about 10%enantiomerically pure R-compound. In certain embodiments, theenantiomerically pure R-compound in such compositions can, for example,comprise, at least about 95% by weight R-compound and at most about 5%by weight S-compound, by total weight of the compound. For example, apharmaceutical composition comprising enantiomerically pure S-compoundcan comprise, for example, about 90% excipient and about 10%enantiomerically pure S-compound. In certain embodiments, theenantiomerically pure S-compound in such compositions can, for example,comprise, at least about 95% by weight S-compound and at most about 5%by weight R-compound, by total weight of the compound. In certainembodiments, the active ingredient can be formulated with little or noexcipient or carrier.

The articles “a” and “an” may be used herein to refer to one or to morethan one (i.e. at least one) of the grammatical objects of the article.By way of example “an analogue” means one analogue or more than oneanalogue.

As used herein, the term “modulation” refers to the inhibition orpotentiation of GABA receptor function. A “modulator” (e.g., a modulatorcompound) may be, for example, an agonist, partial agonist, antagonist,or partial antagonist of the GABA receptor.

“Pharmaceutically acceptable” means approved or approvable by aregulatory agency of the Federal or a state government or thecorresponding agency in countries other than the United States, or thatis listed in the U.S. Pharmacopoeia or other generally recognizedpharmacopoeia for use in animals, and more particularly, in humans.

“Pharmaceutically acceptable salt” refers to a salt of a compound of theinvention that is pharmaceutically acceptable and that possesses thedesired pharmacological activity of the parent compound. In particular,such salts are non-toxic may be inorganic or organic acid addition saltsand base addition salts. Specifically, such salts include: (1) acidaddition salts, formed with inorganic acids such as hydrochloric acid,hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, and thelike; or formed with organic acids such as acetic acid, propionic acid,hexanoic acid, cyclopentanepropionic acid, glycolic acid, pyruvic acid,lactic acid, malonic acid, succinic acid, malic acid, maleic acid,fumaric acid, tartaric acid, citric acid, benzoic acid,3-(4-hydroxybenzoyl) benzoic acid, cinnamic acid, mandelic acid,methanesulfonic acid, ethanesulfonic acid, 1,2-ethane-disulfonic acid,2-hydroxyethanesulfonic acid, benzenesulfonic acid,4-chlorobenzenesulfonic acid, 2-naphthalenesulfonic acid,4-toluenesulfonic acid, camphorsulfonic acid,4-methylbicyclo[2.2.2]-oct-2-ene-1-carboxylic acid, glucoheptonic acid,3-phenylpropionic acid, trimethylacetic acid, tertiary butylacetic acid,lauryl sulfuric acid, gluconic acid, glutamic acid, hydroxynaphthoicacid, salicylic acid, stearic acid, muconic acid, and the like; or (2)salts formed when an acidic proton present in the parent compound eitheris replaced by a metal ion, e.g., an alkali metal ion, an alkaline earthion, or an aluminum ion; or coordinates with an organic base such asethanolamine, diethanolamine, triethanolamine, N-methylglucamine and thelike. Salts further include, by way of example only, sodium, potassium,calcium, magnesium, ammonium, tetraalkylammonium, and the like; and whenthe compound contains a basic functionality, salts of non-toxic organicor inorganic acids, such as hydrochloride, hydrobromide, tartrate,mesylate, acetate, maleate, oxalate and the like. The term“pharmaceutically acceptable cation” refers to an acceptable cationiccounter-ion of an acidic functional group. Such cations are exemplifiedby sodium, potassium, calcium, magnesium, ammonium, tetraalkylammoniumcations, and the like. See, e.g., Berge, et al., J. Pharm. Sci. (1977)66(1): 1-79.

“Solvate” refers to forms of the compound that are associated with asolvent or water (also referred to as “hydrate”), usually by asolvolysis reaction. This physical association includes hydrogenbonding. Conventional solvents include water, ethanol, acetic acid, andthe like. The compounds of the invention may be prepared e.g. incrystalline form and may be solvated or hydrated. Suitable solvatesinclude pharmaceutically acceptable solvates, such as hydrates, andfurther include both stoichiometric solvates and non-stoichiometricsolvates. In certain instances the solvate will be capable of isolation,for example when one or more solvent molecules are incorporated in thecrystal lattice of the crystalline solid. “Solvate” encompasses bothsolution-phase and isolable solvates. Representative solvates includehydrates, ethanolates and methanolates.

“Stereoisomers”: It is also to be understood that compounds that havethe same molecular formula but differ in the nature or sequence ofbonding of their atoms or the arrangement of their atoms in space aretermed “isomers.” Isomers that differ in the arrangement of their atomsin space are termed “stereoisomers.” Stereoisomers that are not mirrorimages of one another are termed “diastereomers” and those that arenon-superimposable mirror images of each other are termed “enantiomers.”When a compound has an asymmetric center, for example, it is bonded tofour different groups, a pair of enantiomers is possible. An enantiomercan be characterized by the absolute configuration of its asymmetriccenter and is described by the R- and S-sequencing rules of Cahn andPrelog, or by the manner in which the molecule rotates the plane ofpolarized light and designated as dextrorotatory or levorotatory (i.e.,as (+) or (−)-isomers respectively). A chiral compound can exist aseither individual enantiomer or as a mixture thereof. A mixturecontaining equal proportions of the enantiomers is called a “racemicmixture”.

“Tautomers” refer to compounds that are interchangeable forms of aparticular compound structure, and that vary in the displacement ofhydrogen atoms and electrons. Thus, two structures may be in equilibriumthrough the movement of π electrons and an atom (usually H). Forexample, enols and ketones are tautomers because they are rapidlyinterconverted by treatment with either acid or base. Another example oftautomerism is the aci- and nitro-forms of phenylnitromethane, that arelikewise formed by treatment with acid or base. Tautomeric forms may berelevant to the attainment of the optimal chemical reactivity andbiological activity of a compound of interest.

“Brexanolone” refers to a sterile solution of 5 mg/mL allopregnanolonein 250 mg/mL sulfobutylether-β-cyclodextrin (SBECD) buffered withcitrate, which is diluted with sterile water for injection to render itisotonic for W infusion.

A “subject” to which administration is contemplated includes, but is notlimited to, humans (i.e., a male or female of any age group, e.g., apediatric subject (e.g, infant, child, adolescent) or adult subject(e.g., young adult, middle-aged adult or senior adult)) and/or anon-human animal, e.g., a mammal such as primates (e.g., cynomolgusmonkeys, rhesus monkeys), cattle, pigs, horses, sheep, goats, rodents,cats, and/or dogs. In certain embodiments, the subject is a human. Incertain embodiments, the subject is a non-human animal. The terms“human,” “patient,” and “subject” are used interchangeably herein.

Disease, disorder, and condition are used interchangeably herein.

As used herein, and unless otherwise specified, the terms “treat,”“treating” and “treatment” contemplate an action that occurs while asubject is suffering from the specified disease, disorder or condition,which reduces the severity of the disease, disorder or condition, orretards or slows the progression of the disease, disorder or condition(“therapeutic treatment”), and also contemplates an action that occursbefore a subject begins to suffer from the specified disease, disorderor condition (“prophylactic treatment”).

As used herein, and unless otherwise specified, a “cycle of treatment”comprises administering a first dose of a neuroactive steroid,administering a second dose of the neuroactive steroid, andadministering a third dose of the neuroactive steroid, said neuroactivesteroid doses being sufficient to treat said subject.

In general, the “effective amount” of a compound refers to an amountsufficient to elicit the desired biological response, e.g., to treat aCNS-related disorder, e.g., a disorder as described herein (e.g., tremor(e.g., essential tremor); depression (e.g., postpartum depression); oran anxiety disorder). As will be appreciated by those of ordinary skillin this art, the effective amount of a compound of the invention mayvary depending on such factors as the desired biological endpoint, thepharmacokinetics of the compound, the disease being treated, the mode ofadministration, and the age, weight, health, and condition of thesubject. An effective amount encompasses therapeutic and prophylactictreatment.

As used herein, and unless otherwise specified, a “therapeuticallyeffective amount” of a compound is an amount sufficient to provide atherapeutic benefit in the treatment of a disease, disorder orcondition, or to delay or minimize one or more symptoms associated withthe disease, disorder or condition. A therapeutically effective amountof a compound means an amount of therapeutic agent, alone or incombination with other therapies, which provides a therapeutic benefitin the treatment of the disease, disorder or condition. The term“therapeutically effective amount” can encompass an amount that improvesoverall therapy, reduces or avoids symptoms or causes of disease orcondition, or enhances the therapeutic efficacy of another therapeuticagent.

As used herein, and unless otherwise specified, a “prophylacticallyeffective amount” of a compound is an amount sufficient to prevent adisease, disorder or condition, or one or more symptoms associated withthe disease, disorder or condition, or prevent its recurrence. Aprophylactically effective amount of a compound means an amount of atherapeutic agent, alone or in combination with other agents, whichprovides a prophylactic benefit in the prevention of the disease,disorder or condition. The term “prophylactically effective amount” canencompass an amount that improves overall prophylaxis or enhances theprophylactic efficacy of another prophylactic agent.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-1B depict an exemplary effect of Compound 9 and diazepam on(FIG. 1A) extrasynaptic or (FIG. 1B) synaptic electrical activity in thebrain.

FIGS. 2A-2B depict an exemplary comparative effect of Compound 9 anddiazepam. (FIG. 2A) PTZ threshold following subchronic dosing for 7 d;and (FIG. 2B) Pharmaco-resistant SE model.

FIGS. 3A-3B depict exemplary preclinical anticonvulsant efficacy inrodents.

FIGS. 4A-4B depict exemplary PK/PD Profile and Brain Exposure forCompound 9. (FIG. 4A) Exposure levels of allopregnanolone and Compound 9following a single oral dose in rat; (FIG. 4B) Exposure levels ofCompound 9 in the plasma and brain of rat.

FIG. 5 shows exemplary pharmacokinetics of Compound 9 during SingleAscending Dose Study.

FIG. 6 shows exemplary pharmacokinetics of Compound 9 during MultipleAscending Dose Study.

FIG. 7 shows exemplary dose linearity over the Multiple Dose RangeStudied.

FIG. 8 shows exemplary MOAA/S Mean Score for Single Ascending DoseStudy.

FIG. 9 shows exemplary MOAA/S Mean Score for Multiple Ascending DoseStudy.

FIG. 10 shows an outline of an exemplary double-blind, randomized,placebo-controlled, Phase 2 registration study of brexanolone in 21hospital inpatient women with severe PPD.

FIG. 11A shows effects of brexanolone or placebo on mean HAM-D totalscore over time in 21 hospital inpatient women with severe PPDparticipating in an exemplary double-blind, randomized,placebo-controlled, Phase 2 registration study of brexanolone.

FIG. 11B shows effects of brexanolone or placebo on mean MADRS totalscore over time in 21 hospital inpatient women with severe PPDparticipating in an exemplary double-blind, randomized,placebo-controlled, Phase 2 registration study of brexanolone.

FIG. 12 shows exemplary HAM-D Remission Rates Over Time in 21 hospitalinpatient women with severe PPD participating in an exemplarydouble-blind, randomized, placebo-controlled, Phase 2 registration studyof brexanolone.

DETAILED DESCRIPTION OF CERTAIN EMBODIMENTS OF THE INVENTION Methods ofUse and Treatment

As generally described herein, the present invention is directed toneuroactive steroids that may act, for example, as GABA modulators. Incertain embodiments, such compounds are envisioned to be useful astherapeutic agents for treating a disorder described herein, e.g.,tremor (e.g., essential tremor); depression (e.g., postpartumdepression, major depressive disorder); an anxiety disorder, comprisingadministering to the subject an effective amount of a compound of thepresent invention or a composition thereof. In certain embodiments, thecompound is administered by intravenous administration. In certainembodiments, the compound is administered orally.

In some embodiments, a compound disclosed herein, for example, aneuroactive steroid described herein such as allopregnanolone orCompound 9, can be administered as a hormone or steroid replacementtherapy in a subject. In an embodiment, a subject described herein hasexperienced a decrease in a steroid or hormone level prior to treatmentwith a compound described herein. For example, a subject generallyexperiences a decrease in allopregnanolone subsequent to delivery of aninfant. In an embodiment, the neuroactive steroid is administered to thesubject within 3 days, 2 days, 1 day, or 24 hours of delivery of a baby(e.g., within 12 hours, within 6 hours, within 3 hours, within 2 hours,within 1 hour, or within 30 minutes). In an embodiment, a subject can beadministered a compound described herein (e.g., allopregnanolone) afterexperiencing a decrease in steroid or hormone level. In an embodiment,the decrease in hormone or steroid level is at least by a factor of 2(e.g., at least a factor of 3, 4, 5, 10 or 100).

Also provided herein is a method for treating or preventing a disorderdescribed herein, comprising orally administering a total daily dose ofCompound 9,

or a pharmaceutically acceptable salt or isotopologue thereof, or apharmaceutical composition thereof of about 10 mg to about 100 mg to asubject in need thereof.

Compounds of the present invention, as described herein, can modulateGABA function, and therefore can act as neuroactive steroids for thetreatment and prevention of CNS-related conditions in a subject.Modulation, as used herein, refers to the inhibition or potentiation ofGABA receptor function. Accordingly, the compounds and pharmaceuticalcompositions provided herein find use as therapeutics for preventingand/or treating CNS conditions in mammals including humans and non-humanmammals. Thus, and as stated earlier, the present invention includeswithin its scope, and extends to, the recited methods of treatment, aswell as to the compounds for such methods, and to the use of suchcompounds for the preparation of medicaments useful for such methods.

Exemplary neuroactive steroid compounds include:

Exemplary CNS conditions related to GABA-modulation include, but are notlimited to, sleep disorders [e.g., insomnia], mood disorders [e.g.,depression such as PND, major depressive disorder, or perinataldepression, dysthymic disorder (e.g., mild depression), bipolar disorder(e.g., I and/or II), anxiety disorders (e.g., generalized anxietydisorder (GAD), social anxiety disorder), stress, post-traumatic stressdisorder (PTSD), compulsive disorders (e.g., obsessive compulsivedisorder (OCD))], schizophrenia spectrum disorders [e.g., schizophrenia,schizoaffective disorder], convulsive disorders [e.g., epilepsy (e.g.,status epilepticus (SE)), seizures], disorders of memory and/orcognition [e.g., attention disorders (e.g., attention deficithyperactivity disorder (ADHD)), dementia (e.g., Alzheimer's typedementia, Lewis body type dementia, vascular type dementia], movementdisorders [e.g., Huntington's disease, Parkinson's disease], personalitydisorders [e.g., anti-social personality disorder, obsessive compulsivepersonality disorder], autism spectrum disorders (ASD) [e.g., autism,monogenetic causes of autism such as synaptophathy's, e.g., Rettsyndrome, Fragile X syndrome, Angelman syndrome], pain [e.g.,neuropathic pain, injury related pain syndromes, acute pain, chronicpain], traumatic brain injury (TBI), vascular diseases [e.g., stroke,ischemia, vascular malformations], substance abuse disorders and/orwithdrawal syndromes [e.g., addition to opiates, cocaine, and/oralcohol], and tinnitus.

In yet another aspect, provided is a combination of a compound of thepresent invention and another pharmacologically active agent. Thecompounds provided herein can be administered as the sole active agentor they can be administered in combination with other agents.Administration in combination can proceed by any technique apparent tothose of skill in the art including, for example, separate, sequential,concurrent and alternating administration.

In another aspect, provided is a method of treating or preventing brainexcitability in a subject susceptible to or afflicted with a conditionassociated with brain excitability, comprising administering to thesubject an effective amount of a compound of the present invention tothe subject.

In yet another aspect, provided is a method of treating or preventingtremor in a subject, comprising administering to the subject in need ofsuch treatment an effective amount of a compound of the presentinvention. In certain embodiments the tremor is essential tremor.

In yet another aspect, provided is a method of treating or preventingmood disorders in a subject, comprising administering to the subject inneed of such treatment an effective amount of a compound of the presentinvention. In certain embodiments the mood disorder is depression. Insome embodiments, the mood disorder is postpartum depression. In someembodiments, the mood disorder is major depressive disorder.

In yet another aspect, provided is a method of alleviating or preventingPMS, PND, major depressive disorder, or perinatal depression in asubject, comprising administering to the subject in need of suchtreatment an effective amount of a compound of the present invention.

In yet another aspect, provided is a method of treating or preventingstress or anxiety in a subject, comprising administering to the subjectin need of such treatment an effective amount of a compound of thepresent invention, or a composition thereof.

In yet another aspect, provided is a method of alleviating or preventinginsomnia in a subject, comprising administering to the subject in needof such treatment an effective amount of a compound of the presentinvention, or a composition thereof.

In yet another aspect, provided is a method of inducing sleep andmaintaining substantially the level of REM sleep that is found in normalsleep, wherein substantial rebound insomnia is not induced, comprisingadministering an effective amount of a compound of the presentinvention.

In yet another aspect, provided is a method of cognition enhancement ortreating memory disorder by administering to the subject atherapeutically effective amount of a compound of the present invention.In certain embodiments, the disorder is Alzheimer's disease. In certainembodiments, the disorder is Rett syndrome.

In yet another aspect, provided is a method of treating attentiondisorders by administering to the subject a therapeutically effectiveamount of a compound of the present invention. In certain embodiments,the attention disorder is ADHD.

In some embodiments, the therapeutic agent (e.g., a neuroactive steroidor compound described herein) is administered to the subject within 3days, 2 days, 1 day, 24 hours of delivery of a baby (e.g., within 12hours, within 6 hours, within 3 hours, within 2 hours, within 1 hour,within 30 minutes).

In an embodiment, the method includes acute treatment of a disorderdescribed herein. For example, in an embodiment, a method describedherein provides relief from a symptom described herein in less than 1week (e.g., within 6 days, 5 days, 4 days, 3 days, 2 days, 1 day, or 12hours). In an embodiment, the subject experiences, upon administrationof a compound described herein (e.g., allopregnanolone) rapid onset ofefficacy of the compound. For example, in an embodiment, a subjectexperiences relief from a symptom of a disorder described herein within1 week (e.g., within 6 days, 5 days, 4 days, 3 days, 2 days, 1 day, or12 hours).

In an embodiment, a method described herein provides for sustainedefficacy upon treatment with a compound described herein. For example,in an embodiment, a subject is treated with a compound described herein,wherein the treatment effectively treats a symptom of a disorderdescribed herein and the efficacy is maintained for at least 1 day(e.g., at least 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks,3 weeks, 1 month, 2 months, 3 months, 4 months, 5 months, or 6 months).In an embodiment, the efficacy is maintained after a single course oftreatment of a compound described herein (e.g., allopregnanolone).Course of treatment, as described herein is a treatment regimenadministered to a subject so as to provide efficacy of a symptom of adisorder to the subject. In an embodiment, a course of treatment is asingle dose. In another embodiment, a course of treatment includesmultiple doses of a compound described herein. In another embodiment, acourse of treatment includes a cycle of treatment of a compounddescribed herein.

In an embodiment, a method described herein can include a course oftreatment with multiple dosages or cycles of treatment, for example,where a first dose or cycle of treatment is a parenteral dose such as anintravenous dose, and a second dose or cycle of treatment is an oraldose. In an embodiment, the first and second dose or cycle of treatmentinclude the same compound described herein. In another embodiment, thefirst dose or cycle of treatment includes a first compound (e.g., afirst compound described herein such as allopregnanolone) and the seconddose or cycle of treatment includes a second compound that is differentfrom the first compound.

In an embodiment, a method described herein provides effective treatmentwithout causing a severe adverse event. In an embodiment, a methoddescribed herein provides effective treatment without causing a moderateor severe adverse event. In an embodiment, a method described hereinprovides effective treatment without causing an adverse event.

In certain embodiments, the compound is administered to the subjectchronically. In certain embodiments, the compound is administered to thesubject orally, subcutaneously, intramuscularly, or intravenously.

Neuroendocrine Disorders and Dysfunction

Provided herein are methods that can be used for treating neuroendocrinedisorders and dysfunction. As used herein, “neuroendocrine disorder” or“neuroendocrine dysfunction” refers to a variety of conditions caused byimbalances in the body's hormone production directly related to thebrain. Neuroendocrine disorders involve interactions between the nervoussystem and the endocrine system. Because the hypothalamus and thepituitary gland are two areas of the brain that regulate the productionof hormones, damage to the hypothalamus or pituitary gland, e.g., bytraumatic brain injury, may impact the production of hormones and otherneuroendocrine functions of the brain. In some embodiments, theneuroendocrine disorder or dysfunction is associated with a women'shealth disorder or condition (e.g., a women's health disorder orcondition described herein). In some embodiments, the neuroendocrinedisorder or dysfunction is associated with a women's health disorder orcondition is polycystic ovary syndrome.

Symptoms of neuroendocrine disorder include, but are not limited to,behavioral, emotional, and sleep-related symptoms, symptoms related toreproductive function, and somatic symptoms; including but not limitedto fatigue, poor memory, anxiety, depression, weight gain or loss,emotional lability, lack of concentration, attention difficulties, lossof lipido, infertility, amenorrhea, loss of muscle mass, increased bellybody fat, low blood pressure, reduced heart rate, hair loss, anemia,constipation, cold intolerance, and dry skin.

Neurodegenerative Diseases and Disorders

The methods described herein can be used for treating neurodegenerativediseases and disorders. The term “neurodegenerative disease” includesdiseases and disorders that are associated with the progressive loss ofstructure or function of neurons, or death of neurons. Neurodegenerativediseases and disorders include, but are not limited to, Alzheimer'sdisease (including the associated symptoms of mild, moderate, or severecognitive impairment); amyotrophic lateral sclerosis (ALS); anoxic andischemic injuries; ataxia and convulsion (including for the treatmentand prevention and prevention of seizures that are caused byschizoaffective disorder or by drugs used to treat schizophrenia);benign forgetfulness; brain edema; cerebellar ataxia including McLeodneuroacanthocytosis syndrome (MLS); closed head injury; coma; contusiveinjuries (e.g., spinal cord injury and head injury); dementias includingmulti-infarct dementia and senile dementia; disturbances ofconsciousness; Down syndrome; drug-induced or medication-inducedParkinsonism (such as neuroleptic-induced acute akathisia, acutedystonia, Parkinsonism, or tardive dyskinesia, neuroleptic malignantsyndrome, or medication-induced postural tremor); epilepsy; fragile Xsyndrome; Gilles de la Tourette's syndrome; head trauma; hearingimpairment and loss; Huntington's disease; Lennox syndrome;levodopa-induced dyskinesia; mental retardation; movement disordersincluding akinesias and akinetic (rigid) syndromes (including basalganglia calcification, corticobasal degeneration, multiple systematrophy, Parkinsonism-ALS dementia complex, Parkinson's disease,postencephalitic parkinsonism, and progressively supranuclear palsy);muscular spasms and disorders associated with muscular spasticity orweakness including chorea (such as benign hereditary chorea,drug-induced chorea, hemiballism, Huntington's disease,neuroacanthocytosis, Sydenham's chorea, and symptomatic chorea),dyskinesia (including tics such as complex tics, simple tics, andsymptomatic tics), myoclonus (including generalized myoclonus and focalcyloclonus), tremor (such as rest tremor, postural tremor, and intentiontremor) and dystonia (including axial dystonia, dystonic writer's cramp,hemiplegic dystonia, paroxysmal dystonia, and focal dystonia such asblepharospasm, oromandibular dystonia, and spasmodic dysphonia andtorticollis); neuronal damage including ocular damage, retinopathy ormacular degeneration of the eye; neurotoxic injury which followscerebral stroke, thromboembolic stroke, hemorrhagic stroke, cerebralischemia, cerebral vasospasm, hypoglycemia, amnesia, hypoxia, anoxia,perinatal asphyxia and cardiac arrest; Parkinson's disease; seizure;status epilecticus; stroke; tinnitus; tubular sclerosis, and viralinfection induced neurodegeneration (e.g., caused by acquiredimmunodeficiency syndrome (AIDS) and encephalopathies).Neurodegenerative diseases also include, but are not limited to,neurotoxic injury which follows cerebral stroke, thromboembolic stroke,hemorrhagic stroke, cerebral ischemia, cerebral vasospasm, hypoglycemia,amnesia, hypoxia, anoxia, perinatal asphyxia and cardiac arrest. Methodsof treating or preventing a neurodegenerative disease also includetreating or preventing loss of neuronal function characteristic ofneurodegenerative disorder.

Epilepsy

The compounds described herein, e.g., the compound of Compound 9, orpharmaceutically acceptable salt, or a pharmaceutically acceptablecomposition thereof, can be used in a method described herein, forexample in the treatment of a disorder described herein such asepilepsy, status epilepticus, or seizure, for example as described inWO2013/112605 and WO/2014/031792, the contents of which are incorporatedherein in their entirety.

Epilepsy is a brain disorder characterized by repeated seizures overtime. Types of epilepsy can include, but are not limited to generalizedepilepsy, e.g., childhood absence epilepsy, juvenile nyoclonic epilepsy,epilepsy with grand-mal seizures on awakening, West syndrome,Lennox-Gastaut syndrome, partial epilepsy, e.g., temporal lobe epilepsy,frontal lobe epilepsy, benign focal epilepsy of childhood.

Status Epilepticus (SE)

Status epilepticus (SE) can include, e.g., convulsive statusepilepticus, e.g., early status epilepticus, established statusepilepticus, refractory status epilepticus, super-refractory statusepilepticus; non-convulsive status epilepticus, e.g., generalized statusepilepticus, complex partial status epilepticus; generalized periodicepileptiform discharges; and periodic lateralized epileptiformdischarges. Convulsive status epilepticus is characterized by thepresence of convulsive status epileptic seizures, and can include earlystatus epilepticus, established status epilepticus, refractory statusepilepticus, super-refractory status epilepticus. Early statusepilepticus is treated with a first line therapy. Established statusepilepticus is characterized by status epileptic seizures which persistdespite treatment with a first line therapy, and a second line therapyis administered. Refractory status epilepticus is characterized bystatus epileptic seizures which persist despite treatment with a firstline and a second line therapy, and a general anesthetic is generallyadministered. Super refractory status epilepticus is characterized bystatus epileptic seizures which persist despite treatment with a firstline therapy, a second line therapy, and a general anesthetic for 24hours or more.

Non-convulsive status epilepticus can include, e.g., focalnon-convulsive status epilepticus, e.g., complex partial non-convulsivestatus epilepticus, simple partial non-convulsive status epilepticus,subtle non-convulsive status epilepticus; generalized non-convulsivestatus epilepticus, e.g., late onset absence non-convulsive statusepilepticus, atypical absence non-convulsive status epilepticus, ortypical absence non-convulsive status epilepticus.

The compounds described herein, e.g., the compound of Compound 9, orpharmaceutically acceptable salt, or a pharmaceutically acceptablecomposition thereof, can also be administered as a prophylactic to asubject having a CNS disorder e.g., a traumatic brain injury, statusepilepticus, e.g., convulsive status epilepticus, e.g., early statusepilepticus, established status epilepticus, refractory statusepilepticus, super-refractory status epilepticus; non-convulsive statusepilepticus, e.g., generalized status epilepticus, complex partialstatus epilepticus; generalized periodic epileptiform discharges; andperiodic lateralized epileptiform discharges; prior to the onset of aseizure.

Seizure

A seizure is the physical findings or changes in behavior that occurafter an episode of abnormal electrical activity in the brain. The term“seizure” is often used interchangeably with “convulsion.” Convulsionsare when a person's body shakes rapidly and uncontrollably. Duringconvulsions, the person's muscles contract and relax repeatedly.

Based on the type of behavior and brain activity, seizures are dividedinto two broad categories: generalized and partial (also called local orfocal). Classifying the type of seizure helps doctors diagnose whetheror not a patient has epilepsy.

Generalized seizures are produced by electrical impulses from throughoutthe entire brain, whereas partial seizures are produced (at leastinitially) by electrical impulses in a relatively small part of thebrain. The part of the brain generating the seizures is sometimes calledthe focus.

There are six types of generalized seizures. The most common anddramatic, and therefore the most well known, is the generalizedconvulsion, also called the grand-mal seizure. In this type of seizure,the patient loses consciousness and usually collapses. The loss ofconsciousness is followed by generalized body stiffening (called the“tonic” phase of the seizure) for 30 to 60 seconds, then by violentjerking (the “clonic” phase) for 30 to 60 seconds, after which thepatient goes into a deep sleep (the “postictal” or after-seizure phase).During grand-mal seizures, injuries and accidents may occur, such astongue biting and urinary incontinence.

Absence seizures cause a short loss of consciousness (just a fewseconds) with few or no symptoms. The patient, most often a child,typically interrupts an activity and stares blankly. These seizuresbegin and end abruptly and may occur several times a day. Patients areusually not aware that they are having a seizure, except that they maybe aware of “losing time.”

Myoclonic seizures consist of sporadic jerks, usually on both sides ofthe body. Patients sometimes describe the jerks as brief electricalshocks. When violent, these seizures may result in dropping orinvoluntarily throwing objects.

Clonic seizures are repetitive, rhythmic jerks that involve both sidesof the body at the same time.

Tonic seizures are characterized by stiffening of the muscles.

Atonic seizures consist of a sudden and general loss of muscle tone,particularly in the arms and legs, which often results in a fall.

Seizures described herein can include epileptic seizures; acuterepetitive seizures; cluster seizures; continuous seizures; unremittingseizures; prolonged seizures; recurrent seizures; status epilepticusseizures, e.g., refractory convulsive status epilepticus, non-convulsivestatus epilepticus seizures; refractory seizures; myoclonic seizures;tonic seizures; tonic-clonic seizures; simple partial seizures; complexpartial seizures; secondarily generalized seizures; atypical absenceseizures; absence seizures; atonic seizures; benign Rolandic seizures;febrile seizures; emotional seizures; focal seizures; gelastic seizures;generalized onset seizures; infantile spasms; Jacksonian seizures;massive bilateral myoclonus seizures; multifocal seizures; neonatalonset seizures; nocturnal seizures; occipital lobe seizures; posttraumatic seizures; subtle seizures; Sylvan seizures; visual reflexseizures; or withdrawal seizures. In some embodiments, the seizure is ageneralized seizure associated with Dravet Syndrome, Lennox-GastautSyndrome, Tuberous Sclerosis Complex, Rett Syndrome or PCDH19 FemalePediatric Epilepsy.

Movement Disorders

Also described herein are methods for treating a movement disorder. Asused herein, “movement disorders” refers to a variety of diseases anddisorders that are associated with hyperkinetic movement disorders andrelated abnormalities in muscle control. Exemplary movement disordersinclude, but are not limited to, Parkinson's disease and parkinsonism(defined particularly by bradykinesia), dystonia, chorea andHuntington's disease, ataxia, tremor (e.g., essential tremor), myoclonusand startle, tics and Tourette syndrome, Restless legs syndrome, stiffperson syndrome, and gait disorders.

Tremor

The methods described herein can be used to treat tremor, for examplecerebellar tremor or intention tremor, dystonic tremor, essentialtremor, orthostatic tremor, parkinsonian tremor, physiological tremor,psychogenic tremor, or rubral tremor. Tremor includes hereditary,degenerative, and idiopathic disorders such as Wilson's disease,Parkinson's disease, and essential tremor, respectively; metabolicdiseases (e.g., thyoid-parathyroid-, liver disease and hypoglycemia);peripheral neuropathies (associated with Charcot-Marie-Tooth,Roussy-Levy, diabetes mellitus, complex regional pain syndrome); toxins(nicotine, mercury, lead, CO, Manganese, arsenic, toluene); drug-induced(narcoleptics, tricyclics, lithium, cocaine, alcohol, adrenaline,bronchodilators, theophylline, caffeine, steroids, valproate,amiodarone, thyroid hormones, vincristine); and psychogenic disorders.Clinical tremor can be classified into physiologic tremor, enhancedphysiologic tremor, essential tremor syndromes (including classicalessential tremor, primary orthostatic tremor, and task- andposition-specific tremor), dystonic tremor, parkinsonian tremor,cerebellar tremor, Holmes' tremor (i.e., rubral tremor), palatal tremor,neuropathic tremor, toxic or drug-induced tremor, and psychogenictremor.

Tremor is an involuntary, at times rhythmic, muscle contraction andrelaxation that can involve oscillations or twitching of one or morebody parts (e.g., hands, arms, eyes, face, head, vocal folds, trunk,legs).

Cerebellar tremor or intention tremor is a slow, broad tremor of theextremities that occurs after a purposeful movement. Cerebellar tremoris caused by lesions in or damage to the cerebellum resulting from,e.g., tumor, stroke, disease (e.g., multiple sclerosis, an inheriteddegenerative disorder).

Dystonic tremor occurs in individuals affected by dystonia, a movementdisorder in which sustained involuntary muscle contractions causetwisting and repetitive motions and/or painful and abnormal postures orpositions. Dystonic tremor may affect any muscle in the body. Dystonictremors occurs irregularly and often can be relieved by complete rest.

Essential tremor or benign essential tremor is the most common type oftremor. Essential tremor may be mild and nonprogressive in some, and maybe slowly progressive, starting on one side of the body but affect bothsides within 3 years. The hands are most often affected, but the head,voice, tongue, legs, and trunk may also be involved. Tremor frequencymay decrease as the person ages, but severity may increase. Heightenedemotion, stress, fever, physical exhaustion, or low blood sugar maytrigger tremors and/or increase their severity. Symptoms generallyevolve over time and can be both visible and persistent following onset.

Orthostatic tremor is characterized by fast (e.g., greater than 12 Hz)rhythmic muscle contractions that occurs in the legs and trunkimmediately after standing. Cramps are felt in the thighs and legs andthe patient may shake uncontrollably when asked to stand in one spot.Orthostatic tremor may occurs in patients with essential tremor.

Parkinsonian tremor is caused by damage to structures within the brainthat control movement. Parkinsonian tremor is often a precursor toParkinson's disease and is typically seen as a “pill-rolling” action ofthe hands that may also affect the chin, lips, legs, and trunk. Onset ofparkinsonian tremor typically begins after age 60. Movement starts inone limb or on one side of the body and can progress to include theother side.

Physiological tremor can occur in normal individuals and have noclinical significance. It can be seen in all voluntary muscle groups.Physiological tremor can be caused by certain drugs, alcohol withdrawal,or medical conditions including an overactive thyroid and hypoglycemia.The tremor classically has a frequency of about 10 Hz.

Psychogenic tremor or hysterical tremor can occur at rest or duringpostural or kinetic movement. Patient with psychogenic tremor may have aconversion disorder or another psychiatric disease.

Rubral tremor is characterized by coarse slow tremor which can bepresent at rest, at posture, and with intention. The tremor isassociated with conditions that affect the red nucleus in the midbrain,classical unusual strokes.

Parkinson's Disease affects nerve cells in the brain that producedopamine. Symptoms include muscle rigidity, tremors, and changes inspeech and gait. Parkinsonism is characterized by tremor, bradykinesia,rigidity, and postural instability. Parkinsonism shares symptoms foundin Parkinson's Disease, but is a symptom complex rather than aprogressive neurodegenerative disease.

Dystonia is a movement disorder characterized by sustained orintermittent muscle contractions causing abnormal, often repetitivemovements or postures. Dystonic movements can be patterned, twisting,and may be tremulous. Dystonia is often initiated or worsened byvoluntary action and associated with overflow muscle activation.

Chorea is a neurological disorder characterized by jerky involuntarymovements typically affecting the shoulders, hips, and face.Huntington's Disease is an inherited disease that causes nerve cells inthe brain to waste away. Symptoms include uncontrolled movements,clumsiness, and balance problems. Huntington's disease can hinder walk,talk, and swallowing.

Ataxia refers to the loss of full control of bodily movements, and mayaffect the fingers, hands, arms, legs, body, speech, and eye movements.

Myloclonus and Startle is a response to a sudden and unexpectedstimulus, which can be acoustic, tactile, visual, or vestibular.

Tics are an involuntary movement usually onset suddenly, brief,repetitive, but non-rhythmical, typically imitating normal behavior andoften occurring out of a background of normal activity. Tics can beclassified as motor or vocal, motor tics associated with movements whilevocal tics associated with sound. Tics can be characterized as simple orcomplex. For example simple motor tics involve only a few musclesrestricted to a specific body part. Tourette Syndrome is an inheritedneuropsychiatric disorder with onset in childhood, characterized bymultiple motor tics and at least one vocal tic.

Restless Legs Syndrome is a neurologic sensorimotor disordercharacterized by an overwhelming urge to move the legs when at rest.

Stiff Person Syndrome is a progressive movement disorder characterizedby involuntary painful spasms and rigidity of muscles, usually involvingthe lower back and legs. Stiff-legged gait with exaggerated lumbarhyperlordosis typically results. Characteristic abnormality on EMGrecordings with continuous motor unit activity of the paraspinal axialmuscles is typically observed. Variants include “stiff-limb syndrome”producing focal stiffness typically affecting distal legs and feet.

Gait disorders refer to an abnormality in the manner or style ofwalking, which results from neuromuscular, arthritic, or other bodychanges. Gait is classified according to the system responsible forabnormal locomotion, and include hemiplegic gait, diplegic gait,neuropathic gait, myopathic gait, parkinsonian gait, choreiform gait,ataxic gait, and sensory gait.

Mood Disorders

Also provided herein are methods for treating a mood disorder, forexample clinical depression, postnatal depression or postpartumdepression, perinatal depression, atypical depression, melancholicdepression, psychotic major depression, cataonic depression, seasonalaffective disorder, dysthymia, double depression, depressive personalitydisorder, recurrent brief depression, minor depressive disorder, bipolardisorder or manic depressive disorder, depression caused by chronicmedical conditions, treatment-resistant depression, refractorydepression, suicidality, suicidal ideation, or suicidal behavior. Insome embodiments, the method described herein provides therapeuticeffect to a subject suffering from depression (e.g., moderate or severedepression). In some embodiments, the mood disorder is associated with adisease or disorder described herein (e.g., neuroendocrine diseases anddisorders, neurodegenerative diseases and disorders (e.g., epilepsy),movement disorders, tremor (e.g., Parkinson's Disease), women's healthdisorders or conditions).

Clinical depression is also known as major depression, major depressivedisorder (MDD), severe depression, unipolar depression, unipolardisorder, and recurrent depression, and refers to a mental disordercharacterized by pervasive and persistent low mood that is accompaniedby low self-esteem and loss of interest or pleasure in normallyenjoyable activities. Some people with clinical depression have troublesleeping, lose weight, and generally feel agitated and irritable.Clinical depression affects how an individual feels, thinks, and behavesand may lead to a variety of emotional and physical problems.Individuals with clinical depression may have trouble doing day-to-dayactivities and make an individual feel as if life is not worth living.

Peripartum depression refers to depression in pregnancy. Symptomsinclude irritability, crying, feeling restless, trouble sleeping,extreme exhaustion (emotional and/or physical), changes in appetite,difficulty focusing, increased anxiety and/or worry, disconnectedfeeling from baby and/or fetus, and losing interest in formerlypleasurable activities.

Postnatal depression (PND) is also referred to as postpartum depression(PPD), and refers to a type of clinical depression that affects womenafter childbirth. Symptoms can include sadness, fatigue, changes insleeping and eating habits, reduced sexual desire, crying episodes,anxiety, and irritability. In some embodiments, the PND is atreatment-resistant depression (e.g., a treatment-resistant depressionas described herein). In some embodiments, the PND is refractorydepression (e.g., a refractory depression as described herein).

In some embodiments, a subject having PND also experienced depression,or a symptom of depression during pregnancy. This depression is referredto herein as) perinatal depression. In an embodiment, a subjectexperiencing perinatal depression is at increased risk of experiencingPND.

Atypical depression (AD) is characterized by mood reactivity (e.g.,paradoxical anhedonia) and positivity, significant weight gain orincreased appetite. Patients suffering from AD also may have excessivesleep or somnolence (hypersomnia), a sensation of limb heaviness, andsignificant social impairment as a consequence of hypersensitivity toperceived interpersonal rejection.

Melancholic depression is characterized by loss of pleasure (anhedonia)in most or all activities, failures to react to pleasurable stimuli,depressed mood more pronounced than that of grief or loss, excessiveweight loss, or excessive guilt.

Psychotic major depression (PMD) or psychotic depression refers to amajor depressive episode, in particular of melancholic nature, where theindividual experiences psychotic symptoms such as delusions andhallucinations.

Catatonic depression refers to major depression involving disturbancesof motor behavior and other symptoms. An individual may become mute andstuporose, and either is immobile or exhibits purposeless or bizarremovements.

Seasonal affective disorder (SAD) refers to a type of seasonaldepression wherein an individual has seasonal patterns of depressiveepisodes coming on in the fall or winter.

Dysthymia refers to a condition related to unipolar depression, wherethe same physical and cognitive problems are evident. They are not assevere and tend to last longer (e.g., at least 2 years).

Double depression refers to fairly depressed mood (dysthymia) that lastsfor at least 2 years and is punctuated by periods of major depression.

Depressive Personality Disorder (DPD) refers to a personality disorderwith depressive features.

Recurrent Brief Depression (RBD) refers to a condition in whichindividuals have depressive episodes about once per month, each episodelasting 2 weeks or less and typically less than 2-3 days.

Minor depressive disorder or minor depression refers to a depression inwhich at least 2 symptoms are present for 2 weeks.

Bipolar disorder or manic depressive disorder causes extreme mood swingsthat include emotional highs (mania or hypomania) and lows (depression).During periods of mania the individual may feel or act abnormally happy,energetic, or irritable. They often make poorly thought out decisionswith little regard to the consequences. The need for sleep is usuallyreduced. During periods of depression there may be crying, poor eyecontact with others, and a negative outlook on life. The risk of suicideamong those with the disorder is high at greater than 6% over 20 years,while self harm occurs in 30-40%. Other mental health issues such asanxiety disorder and substance use disorder are commonly associated withbipolar disorder.

Depression caused by chronic medical conditions refers to depressioncaused by chronic medical conditions such as cancer or chronic pain,chemotherapy, chronic stress.

Treatment-resistant depression refers to a condition where theindividuals have been treated for depression, but the symptoms do notimprove. For example, antidepressants or psychological counseling(psychotherapy) do not ease depression symptoms for individuals withtreatment-resistant depression. In some cases, individuals withtreatment-resistant depression improve symptoms, but come back.Refractory depression occurs in patients suffering from depression whoare resistant to standard pharmacological treatments, includingtricyclic antidepressants, MAOIs, SSRIs, and double and triple uptakeinhibitors and/or anxiolytic drugs, as well as non-pharmacologicaltreatments (e.g., psychotherapy, electroconvulsive therapy, vagus nervestimulation and/or transcranial magnetic stimulation).

Post-surgical depression refers to feelings of depression that follow asurgical procedure (e.g., as a result of having to confront one'smortality). For example, individuals may feel sadness or empty moodpersistently, a loss of pleasure or interest in hobbies and activitiesnormally enjoyed, or a persistent felling of worthlessness orhopelessness.

Mood disorder associated with conditions or disorders of women's healthrefers to mood disorders (e.g., depression) associated with (e.g.,resulting from) a condition or disorder of women's health (e.g., asdescribed herein).

Suicidality, suicidal ideation, suicidal behavior refers to the tendencyof an individual to commit suicide. Suicidal ideation concerns thoughtsabout or an unusual preoccupation with suicide. The range of suicidalideation varies greatly, from e.g., fleeting thoughts to extensivethoughts, detailed planning, role playing, incomplete attempts. Symptomsinclude talking about suicide, getting the means to commit suicide,withdrawing from social contact, being preoccupied with death, feelingtrapped or hopeless about a situation, increasing use of alcohol ordrugs, doing risky or self-destructive things, saying goodbye to peopleas if they won't be seen again.

Symptoms of depression include persistent anxious or sad feelings,feelings of helplessness, hopelessness, pessimism, worthlessness, lowenergy, restlessness, difficulty sleeping, sleeplessness, irritability,fatigue, motor challenges, loss of interest in pleasurable activities orhobbies, loss of concentration, loss of energy, poor self-esteem,absence of positive thoughts or plans, excessive sleeping, overeating,appetite loss, insomnia, self-harm, thoughts of suicide, and suicideattempts. The presence, severity, frequency, and duration of symptomsmay vary on a case to case basis. Symptoms of depression, and relief ofthe same, may be ascertained by a physician or psychologist (e.g., by amental state examination).

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Hamilton Depression Score (HAM-D)) within 4, 3,2, 1 days; 96, 84, 72, 60, 48, 24, 20, 16, 12, 10, 8 hours or less. Insome embodiments, the therapeutic effect is a decrease from baseline inHAM-D score at the end of a treatment period (e.g., 12, 24, 48 hoursafter administration; 24, 48, 72, 96 hours or more). In someembodiments, the decrease from baseline in HAM-D score is from severe(e.g., HAM-D score of 24 or greater) to symptom-free (e.g., HAM-D scoreof 7 or lower). In some embodiments, the baseline score is about 10 to52 (e.g., more than 10, 15, or 20; 10 to 52, 12 to 52, 15 to 52, 17 to52, 20 to 52, 22 to 52). In some embodiments, the baseline score is atleast 10, 15, or 20. In some embodiments, the HAM-D score at the end ofthe treatment period is about 0 to 10 (e.g., less than 10; 0 to 10, 0 to6, 0 to 4, 0 to 3, 0 to 2, 1.8). In some embodiments, the HAM-D score atthe end of the treatment period is less than 10, 7, 5, or 3. In someembodiments, the decrease in HAM-D score is from a baseline score ofabout 20 to 30 (e.g., 22 to 28, 23 to 27, 24 to 27, 25 to 27, 26 to 27)to a HAM-D score at the end of the treatment period is about 0 to 10(e.g., less than 10; 0 to 10, 0 to 6, 0 to 4, 0 to 3, 0 to 2, 1.8). Insome embodiments, the decrease in the baseline HAM-D score to HAM-Dscore at the end of the treatment period is at least 1, 2, 3, 4, 5, 7,10, 25, 40, 50, or 100 fold). In some embodiments, the percentagedecrease in the baseline HAM-D score to HAM-D score at the end of thetreatment period is at least 50% (e.g., 60%, 70%, 80%, 90%). In someembodiments, the therapeutic effect is a decrease from baseline in HAM-Dscore at the end of a treatment period (e.g., 12, 24, 48 hours afteradministration; 24, 48, 72, 96 hours or more) at least 10, 15, or 20points. In some embodiments, the therapeutic effect is a decrease frombaseline in HAM-D score at the end of a treatment period (e.g., 12, 24,48 hours after administration; 24, 48, 72, 96 hours or more) at least 5,7, or 10 points more relative to the therapeutic effect provided by aplacebo treatment.

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Montgomery-Asberg Depression Rating Scale(MADRS)) within 4, 3, 2, 1 days; 96, 84, 72, 60, 48, 24, 20, 16, 12, 10,8 hours or less. The Montgomery-Åsberg Depression Rating Scale (MADRS)is a ten-item diagnostic questionnaire (regarding apparent sadness,reported sadness, inner tension, reduced sleep, reduced appetite,concentration difficulties, lassitude, inability to feel, pessimisticthoughts, and suicidal thoughts) which psychiatrists use to measure theseverity of depressive episodes in patients with mood disorders. 0-6indicates normal/symptom absent; 7-19 indicates mild depression; 20-34indicates moderate depression; and >34 indicates severe depression. Insome embodiments, the therapeutic effect is a decrease from baseline inMADRS score at the end of a treatment period (e.g., 12, 24, 48 hoursafter administration; 24, 48, 60, 72, 96 hours or more). In someembodiments, the decrease from baseline in MADRS score is from severe(e.g., MADRS score of 30 or greater) to symptom-free (e.g., MADRS scoreof 20 or lower). For example, the mean change from baseline in MADRStotal score from treatment with a compound described herein is about−15, −20, −25, −30, while the mean change from baseline in MADRS totalscore from treatment with placebo is about −15, −10, −5.

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Edinburgh Postnatal Depression Scale (EPDS))within 4, 3, 2, 1 days; 24, 20, 16, 12, 10, 8 hours or less. In someembodiments, the therapeutic effect is a improvement measured by theEPDS.

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Clinical Global Impression-Improvement Scale(CGI)) within 4, 3, 2, 1 days; 24, 20, 16, 12, 10, 8 hours or less. Insome embodiments, the therapeutic effect is a CGI score of 2 or less.

In some embodiments, the method provides therapeutic effect (e.g., asmeasured by reduction in Generalized Anxiety Disorder 7-Item Scale(GAD-7)) within 4, 3, 2, 1 days; 24, 20, 16, 12, 10, 8 hours or less.

Anxiety Disorders

Provided herein are methods for treating anxiety disorders (e.g.,generalized anxiety disorder, panic disorder, obsessive compulsivedisorder, phobia, post-traumatic stress disorder). Anxiety disorder is ablanket term covering several different forms of abnormal andpathological fear and anxiety. Current psychiatric diagnostic criteriarecognize a wide variety of anxiety disorders.

Generalized anxiety disorder is a common chronic disorder characterizedby long-lasting anxiety that is not focused on any one object orsituation. Those suffering from generalized anxiety experiencenon-specific persistent fear and worry and become overly concerned witheveryday matters. Generalized anxiety disorder is the most commonanxiety disorder to affect older adults.

In panic disorder, a person suffers from brief attacks of intense terrorand apprehension, often marked by trembling, shaking, confusion,dizziness, nausea, difficulty breathing. These panic attacks, defined bythe APA as fear or discomfort that abruptly arises and peaks in lessthan ten minutes, can last for several hours and can be triggered bystress, fear, or even exercise; although the specific cause is notalways apparent. In addition to recurrent unexpected panic attacks, adiagnosis of panic disorder also requires that said attacks have chronicconsequences: either worry over the attacks' potential implications,persistent fear of future attacks, or significant changes in behaviorrelated to the attacks. Accordingly, those suffering from panic disorderexperience symptoms even outside of specific panic episodes. Often,normal changes in heartbeat are noticed by a panic sufferer, leadingthem to think something is wrong with their heart or they are about tohave another panic attack. In some cases, a heightened awareness(hypervigilance) of body functioning occurs during panic attacks,wherein any perceived physiological change is interpreted as a possiblelife threatening illness (i.e. extreme hypochondriasis).

Obsessive compulsive disorder is a type of anxiety disorder primarilycharacterized by repetitive obsessions (distressing, persistent, andintrusive thoughts or images) and compulsions (urges to perform specificacts or rituals). The OCD thought pattern may be likened tosuperstitions insofar as it involves a belief in a causativerelationship where, in reality, one does not exist. Often the process isentirely illogical; for example, the compulsion of walking in a certainpattern may be employed to alleviate the obsession of impending harm.And in many cases, the compulsion is entirely inexplicable, simply anurge to complete a ritual triggered by nervousness. In a minority ofcases, sufferers of OCD may only experience obsessions, with no overtcompulsions; a much smaller number of sufferers experience onlycompulsions.

The single largest category of anxiety disorders is that of phobia,which includes all cases in which fear and anxiety is triggered by aspecific stimulus or situation. Sufferers typically anticipateterrifying consequences from encountering the object of their fear,which can be anything from an animal to a location to a bodily fluid.

Post-traumatic stress disorder or PTSD is an anxiety disorder whichresults from a traumatic experience. Post-traumatic stress can resultfrom an extreme situation, such as combat, rape, hostage situations, oreven serious accident. It can also result from long term (chronic)exposure to a severe stressor, for example soldiers who endureindividual battles but cannot cope with continuous combat. Commonsymptoms include flashbacks, avoidant behaviors, and depression.

Women's Health Disorders

Provided herein are methods for treating conditions or disorders relatedto women's health. Conditions or disorders related to women's healthinclude, but are not limited to, Gynecological health and disorders(e.g., premenstrual syndrome (PMS), premenstrual dysphoric disorder(PMDD)), pregnancy issues (e.g., miscarriage, abortion), infertility andrelated disorders (e.g., polycystic ovary syndrome (PCOS)), otherdisorders and conditions, and issues related to women's overall healthand wellness (e.g., menopause).

Gynecological health and disorders affecting women include menstruationand menstrual irregularities; urinary tract health, including urinaryincontinence and pelvic floor disorders; and such disorders as bacterialvaginosis, vaginitis, uterine fibroids, and vulvodynia.

Premenstrual syndrome (PMS) refers to physical and emotional symptomsthat occur in the one to two weeks before a women's period. Symptomsvary but can include bleeding, mood swings, tender breasts, foodcravings, fatigue, irritability, acne, and depression.

Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. Thesymptoms of PMDD are similar to PMS but more severe and may interferewith work, social activity, and relationships. PMDD symptoms includemood swings, depressed mood or feelings of hopelessness, marked anger,increased interpersonal conflicts, tension and anxiety, irritability,decreased interest in usual activities, difficulty concentrating,fatigue, change in appetite, feeling out of control or overwhelmed,sleep problems, physical problems (e.g., bloating, breast tenderness,swelling, headaches, joint or muscle pain).

Pregnancy issues include preconception care and prenatal care, pregnancyloss (miscarriage and stillbirth), preterm labor and premature birth,sudden infant death syndrome (SIDS), breastfeeding, and birth defects.

Miscarriage refers to a pregnancy that ends on its own, within the first20 weeks of gestation.

Abortion refers to the deliberate termination of a pregnancy, which canbe performed during the first 28 weeks of pregnancy.

Infertility and related disorders include uterine fibroids, polycysticovary syndrome, endometriosis, and primary ovarian insufficiency.

Polycystic ovary syndrome (PCOS) refers to an endocrine system disorderamong women of reproductive age. PCOS is a set of symptoms resultingfrom an elevated male hormone in women. Most women with PCOS grow manysmall cysts on their ovaries. Symptoms of PCOS include irregular or nomenstrual periods, heavy periods, excess body and facial hair, acne,pelvic pain, difficulty getting pregnant, and patches of thick, darker,velvety skin. PCOS may be associated with conditions including type 2diabetes, obesity, obstructive sleep apnea, heart disease, mooddisorders, and endometrial cancer.

Other disorders and conditions that affect only women include Turnersyndrome, Rett syndrome, and ovarian and cervical cancers.

Issues related to women's overall health and wellness include violenceagainst women, women with disabilities and their unique challenges,osteoporosis and bone health, and menopause.

Menopause refers to the 12 months after a woman's last menstrual periodand marks the end of menstrual cycles. Menopause typically occurs in awoman's 40 s or 50 s. Physical symptoms such as hot flashes andemotional symptoms of menopause may disrupt sleep, lower energy, ortrigger anxiety or feelings of sadness or loss. Menopause includesnatural menopause and surgical menopause, which is a type of inducedmenopause due to an event such as surgery (e.g., hysterectomy,oophorectomy; cancer). It is induced when the ovaries are gravelydamaged by, e.g., radiation, chemotherapy, or other medications.

Neuroactive Steroids

Neuroactive steroids (or neurosteroids) are natural, synthetic, orsemi-synthetic steroids that rapidly alter neuronal excitability throughinteraction with neurotransmitter-gated ion channels. Neuroactivesteroids effect binding to membrane-bound receptors such as those forinhibitory and (or) excitatory neurotransmitters including GABA_(A),NMDA, and sigma receptors.

The steroids that may be classified into functional groups according tochemical structure and physiological activity and include estrogenichormones, progestational hormones, and androgenic hormones. Ofparticular interest are progestational hormones, referred to herein as“progestins” or “progestogens”, and their derivatives and bioactivemetabolites. Members of this broad family include steroid hormonesdisclosed in Remington's Pharmaceutical Sciences, Gennaro et al., MackPublishing Co. (18th ed. 1990), 990-993. As with all other classes ofsteroids, stereoisomerism is of fundamental importance with the sexhormones. As used herein, a variety of progestins (e.g., progesterone)and their derivatives, including both synthetic and natural products,can be used, as well as progestin metabolites such as progesterone.

The term “progesterone” as used herein refers to a member of theprogestin family and includes a 21 carbon steroid hormone. Progesteroneis also known as D4-pregnene-3,20-dione; Δ4-pregnene-3,20-dione; orpregn-4-ene-3,20-dione. As used herein a “synthetic progestin” is amolecule whose structure is related to that of progesterone, issynthetically derived, and retains the biological activity ofprogesterone.

Representative synthetic progestins include, but are not limited to,substitutions at the 17-position of the progesterone ring to introduce ahydroxyl, acetyl, hydroxyl acetyl, aliphatic, nitro, or heterocyclicgroup, modifications to produce 17α-OH esters (e.g.,17α-hydroxyprogesterone caproate), as well as modifications thatintroduce 6-methyl, 6-ene, and 6-chloro substituents onto progesterone(e.g., medroxyprogesterone acetate, megestrol acetate, and chlomadinoneacetate), and which retains the biological activity of progesterone.Such progestin derivatives include 5-dehydroprogesterone,6-dehydro-retroprogesterone (dydrogesterone), allopregnanolone(allopregnan-3α, or 3β-ol-20-one), ethynodiol diacetate,hydroxyprogesterone caproate (pregn-4-ene-3,20-dione,17-(1-oxohexy)oxy); levonorgestrel, norethindrone, norethindrone acetate(19-norpregn-4-en-20-yn-3-one, 17-(acetyloxy)-,(17α)-); norethynodrel,norgestrel, pregnenolone, ganaxolone (also referred to as CCD-1042 orINN), and megestrol acetate. In some embodiments, the neuroactivesteroid is ganaxolone.

Useful progestins also can include allopregnone-3α or 3β, 20α or20β-diol (see Merck Index 258-261); allopregnane-3β,21-diol-11,20-dione;allopregnane-3β,17α-diol-20-one; 3,20-allopregnanedione, allopregnane,3β,11β,17α,20β,21-pentol; allopregnane-3β,17α,20β,21-tetrol;allopregnane-3α or 3β,11β,17α,21-tetrol-20-one, allopregnane-3β,17α or20β-triol; allopregnane-3β,17α,21-triol-11,20-dione;allopregnane-3β,11β,21-triol-20-one;allopregnane-3β,17α,21-triol-20-one; allopregnane-3α or 3β-ol-20-one;pregnanediol; 3,20-pregnanedione; pregnan-3α-ol-20-one;4-pregnene-20,21-diol-3,11-dione;4-pregnene-11β,17α,20β,21-tetrol-3-one;4-pregnene-17α,20β,21-triol-3,11-dione;4-pregnene-17α,20β,21-triol-3-one, and pregnenolone methyl ether.Further progestin derivatives include esters with non-toxic organicacids such as acetic acid, benzoic acid, maleic acid, malic acid,caproic acid, and citric acid and inorganic salts such as hydrochloride,sulfate, nitrate, bicarbonate and carbonate salts. Other suitableprogestins include alphaxalone (also referred to as INN, alfaxolone, andalphaxolone), alphadolone (also referred to as alfadolone),hydroxydione, and minaxolone. In some embodiments, the neuroactivesteroid is alphaxolone.

Additional suitable neuroactive steroids are disclosed in WIPOPublication Nos. WO2013/188792, WO 2013/056181, WO2015/010054,WO2014/169832, WO2014/169836, WO2014/169833, WO2014/169831,WO2015/027227, WO 2014/100228, U.S. Pat. Nos. 5,232,917, 8,575,375 and8,759,330, which are incorporated herein by reference for theneuroactive steroids described therein.

In some embodiments, the therapeutic agent is a neuroactive steroid(e.g., a neuroactive steroid selected from pregnanolone, ganaxolone,alphadalone, alphaxalone, and allopregnanolone).

Exemplary neuroactive steroid compounds include:

In particular embodiments, the steroids are one or more of a series ofsedative-hypnotic 3 alpha-hydroxy ring A-reduced pregnane steroids thatinclude the major metabolites of progesterone and deoxycorticosterone, 3alpha-hydroxy-5 alpha-pregnan-20-one (allopregnanolone) and 3alpha,21-dihydroxy-5 alpha-pregnan-20-one (allotetrahydroDOC),respectively. These 3 alpha-hydroxysteroids do not interact withclassical intracellular steroid receptors but bind stereoselectively andwith high affinity to receptors for the major inhibitoryneurotransmitter in the brain, gamma-amino-butyric acid (GABA).

In certain embodiments, the neuroactive steroids are progesterone,pregnanolone, allopregnanolone, alphadalone, ganaxolone, or alphaxoloneor other progesterone analogs. In a particular embodiment, theneuroactive steroid is allopregnanolone or a derivative thereof. In someembodiments, the neuroactive steroid is allopregnanolone. Exemplaryderivatives include, but are not limited to,(20R)-17beta-(1-hydroxy-2,3-butadienyl)-5alpha-androstane-3alpha-ol(HBAO). Additional derivatives are described in WO 2012/127176.

In some embodiments, the neuroactive steroid is allopregnanolone. Insome embodiments, the neuroactive steroid is ganaxolone. In someembodiments, the neuroactive steroid is alphaxolone.

As used herein, the neuroactive steroids described herein, e.g.,“allopregnanolone,” “ganaxolone,” and “alphaxolone,” also encompassespharmaceutically acceptable, pharmacologically active derivativesincluding individual enantiomers (dextrogyral and levrogyralenantiomers) and their pharmaceutically acceptable salts, mixtures ofenantiomers and their pharmaceutically acceptable salts, and activemetabolites and their pharmaceutically acceptable salts, unlessotherwise noted. It is understood that in some cases dosages ofenantiomers, derivatives, and metabolites may need to be adjusted basedon relative activity of the racemic mixture of the neuroactive steroid,e.g., pregnanolone, allopregnanolone, alphadalone, ganaxolone, oralphaxolone.

The lipophilic nature of the neuroactive steroid (e.g., pregnanolone,allopregnanolone, alphadalone, ganaxolone, or alphaxolone), can make itdifferent to formulate for in vivo administration. As discussed above,the neuroactive steroid (e.g., pregnanolone, allopregnanolone,alphadalone, ganaxolone, or alphaxolone), can be formulated with a host,such as a cyclodextrin to improve the solubility. Alternatively, oradditionally, the neuroactive steroid (e.g., pregnanolone,allopregnanolone, alphadalone, ganaxolone, or alphaxolone), can bemodified in an attempt to improve the solubility. For example, polargroups can be introduced onto position 16a with the goal of increasingwater solubility, brain accessibility, and potency of neuroactivesteroids as described in Kasal et al., J Med. Chem., 52(7), 2119-215(2009).

Solubilization of Neuroactive Steroids

Some neuroactive steroids possess limited aqueous solubility. In orderto provide formulations capable of delivering therapeutically effectivedosages, a variety of methods can be employed to enhance the solubilityand bioavailability of neuroactive steroids. See, for example,“Water-Insoluble Drug Formulation”, 2nd Edition, edited by Rong Liu (CRCPress, Boca Raton, FL, 2008). Using the techniques described below, asolubilized formulation of one or more neuroactive steroids can beprepared.

Inclusion Complexes

The solubility of neuroactive steroids can be improved by inclusioncomplexation (e.g., host-guest formulations). Inclusion complexes areformed when a nonpolar molecule (i.e., the guest, such as a drug withpoor aqueous stability) or portion of a molecule inserts into a nonpolarcavity of another molecule or group of molecules (i.e., the host). Ifthe host molecule or molecules exhibit water good solubility, thesolubility of the host-guest complex will be greater than the solubilityof the guest alone.

Inclusion complexes containing or comprising one or more neuroactivesteroids can be formed using any suitable host molecule or molecules.For example, the water solubility of neuroactive steroids can beincreased by inclusion complexation with cyclodextrins.Steroid-cyclodextrin complexes are known in the art. See, for example,U.S. Pat. No. 7,569,557 to Backensfeld, et al., and U.S. PatentApplication Publication No. US 2006/0058262 to Zoppetti, et al.

Dextrans are soluble polysaccharides produced by bacteria and yeasts.They are characterized by a predominance (>95%) of α (1-6) backbonelinkages and varying proportions of α(1-2), α(1-3) and α(1-4) linkagestypically at branch points 1, 2. Dextrins are partially hydrolyzedglucose homopolymers composed exclusively of α(1-4) backbone linkages.

Cyclodextrins are cyclic oligosaccharides containing or comprising six(α-cyclodextrin), seven (β-cyclodextrin), eight (γ-cyclodextrin), ormore α-(1,4)-linked glucose residues. The hydroxyl groups of thecyclodextrins are oriented to the outside of the ring while theglucosidic oxygen and two rings of the non-exchangeable hydrogen atomsare directed towards the interior of the cavity. As a result,cyclodextrins possess a hydrophobic inner cavity combined with ahydrophilic exterior which conveys water solubility. Upon combinationwith a hydrophobic drug, such as a neuroactive steroid, the neuroactivesteroid (i.e., the guest) inserts into the hydrophobic interior of thecyclodextrin (i.e., the host). The host-guest complex retains watersolubility as a consequence of the hydrophobic exterior of thecyclodextrin ring.

Neuroactive steroid-cyclodextrin complexes can, as solubility permits,be incorporated into any of the parenteral and non-parenteralformulations described below. If desired, the aqueous solubility ofsolid neuoractive steroid-cyclodextrin complexes can be further enhancedby isolating the neuoractive steroid-cyclodextrin complex as a solid vialyophilization and/or via micronizing the solid neuoractivesteroid-cyclodextrin complex.

This cyclic orientation provides a truncated cone structure that ishydrophilic on the exterior and lipophilic on the interior. Cyclodextrincomplexes are formed when a guest molecule is partially or fullycontained in the interior of the cavity. The parent α-, β-, andγ-cyclodextrins (particularly β) have limited aqueous solubility andshow toxicity when given parenterally. Therefore, the parentcyclodextrin structure can be chemically modified to generate aparenterally safe CD-derivative. The modifications are typically made atone or more of the 2, 3, or 6 position hydroxyls.

Neuroactive steroid-cyclodextrin complexes are preferably formed from acyclodextrin selected from the group consisting of α-cyclodextrin,β-cyclodextrin, γ-cyclodextrin, and derivatives thereof. Thecyclodextrin may be chemically modified such that some or all of theprimary or secondary hydroxyl groups of the macrocycle, or both, arefunctionalized with a pendant group. Suitable pendant groups include,but are not limited to, sulfinyl, sulfonyl, phosphate, acyl, and C₁-C₁₂alkyl groups optionally substituted with one or more (e.g., 1, 2, 3, or4) hydroxy, carboxy, carbonyl, acyl, oxy, oxo; or a combination thereof.Methods of modifying these alcohol residues are known in the art, andmany cyclodextrin derivatives are commercially available, includingsulfo butyl ether β-cyclodextrins available under the trade nameCAPTISOL® from Ligand Pharmaceuticals (La Jolla, CA).

Examples of suitable cyclodextrins for use in neuroactive steroid, e.g.,pregnanolone, allopregnanolone, alphadalone, ganaxolone, or alphaxoloneformulations, can include cyclodextrins disclosed in U.S. Pat. Nos.5,874,418; 6,046,177; and 7,635,733, which are herein incorporated byreference. Other examples of suitable cyclodextrins for use inneuroactive steroid formulations non-exclusively include α-cyclodextrin;β-cyclodextrin; γ-cyclodextrin; methyl α-cyclodextrin; methylβ-cyclodextrin; methyl γ-cyclodextrin; ethyl β-cyclodextrin; butylα-cyclodextrin; butyl β-cyclodextrin; butyl γ-cyclodextrin; pentylγ-cyclodextrin; hydroxyethyl β-cyclodextrin; hydroxyethylγ-cyclodextrin; 2-hydroxypropyl α-cyclodextrin; 2-hydroxypropylβ-cyclodextrin; 2-hydroxypropyl γ-cyclodextrin; 2-hydroxybutylβ-cyclodextrin; acetyl α-cyclodextrin; acetyl β-cyclodextrin; acetylγ-cyclodextrin; propionyl β-cyclodextrin; butyryl β-cyclodextrin;succinyl α-cyclodextrin; succinyl β-cyclodextrin; succinylγ-cyclodextrin; benzoyl β-cyclodextrin; palmityl β-cyclodextrin;toluenesulfonyl β-cyclodextrin; acetyl methyl β-cyclodextrin; acetylbutyl β-cyclodextrin; glucosyl α-cyclodextrin; glucosyl β-cyclodextrin;glucosyl γ-cyclodextrin; maltosyl α-cyclodextrin; maltosylβ-cyclodextrin; maltosyl γ-cyclodextrin; α-cyclodextrincarboxymethylether; O-cyclodextrin carboxymethylether; γ-cyclodextrincarboxymethylether; carboxymethylethyl β-cyclodextrin; phosphate esterα-cyclodextrin; phosphate ester β-cyclodextrin; phosphate esterγ-cyclodextrin; 3-trimethylammonium-2-hydroxypropyl β-cyclodextrin;sulfobutyl ether β-cyclodextrin; carboxymethyl α-cyclodextrin;carboxymethyl β-cyclodextrin; carboxymethyl γ-cyclodextrin, andcombinations thereof.

Preferred cyclodextrins include, but are not limited to, alkylcyclodextrins, hydroxy alkyl cyclodextrins, such as hydroxy propylβ-cyclodextrin, carboxy alkyl cyclodextrins and sulfoalkyl ethercyclodextrins, such as sulfo butyl ether β-cyclodextrin.

In particular embodiments, the cyclodextrin is a alpha, beta, or gammacyclodextrin having a plurality of charges (e.g., negative or positive)on the surface. In more particular embodiments, the cyclodextrin is aβ-cyclodextrin containing or comprising a plurality of functional groupsthat are negatively charged at physiological pH. Examples of suchfunctional groups include, but are not limited to, carboxylic acid(carboxylate) groups, sulfonate (RSO₃ ⁻), phosphonate groups,phosphinate groups, and amino acids that are negatively charged atphysiological pH. The charged functional groups can be bound directly tothe cyclodextrins or can be linked by a spacer, such as an alkylenechain. The number of carbon atoms in the alkylene chain can be varied,but is generally between about 1 and 10 carbons, preferably 1-6 carbons,more preferably 1-4 carbons. Highly sulfated cyclodextrins are describedin U.S. Pat. No. 6,316,613.

In one embodiment, the cyclodextrins is a β-cyclodextrin functionalizedwith a plurality of sulfobutyl ether groups. Such a cyclodextrins issold under the trade name CAPTISOL®.

CAPTISOL® is a polyanionic beta-cyclodextrin derivative with a sodiumsulfonate salt separated from the lipophilic cavity by a butyl etherspacer group, or sulfobutylether (SBE). CAPTISOL® is not a singlechemical species, but comprised of a multitude of polymeric structuresof varying degrees of substitution and positional/regional isomersdictated and controlled to a uniform pattern by a patented manufacturingprocess consistently practiced and improved to control impurities.

CAPTISOL® contains six to seven sulfobutyl ether groups per cyclodextrinmolecule. Because of the very low pKa of the sulfonic acid groups,CAPTISOL® carries multiple negative charges at physiologicallycompatible pH values. The four-carbon butyl chain coupled with repulsionof the end group negative charges allows for an “extension” of thecyclodextrin cavity. This often results in stronger binding to drugcandidates than can be achieved using other modified cyclodextrins. Italso provides a potential for ionic charge interactions between thecyclodextrin and a positively charged drug molecule. In addition, thesederivatives impart exceptional solubility and parenteral safety to themolecule. Relative to beta-cyclodextrin, CAPTISOL® provides higherinteraction characteristics and superior water solubility in excess of100 grams/100 ml, a 50-fold improvement.

In other embodiments, the cyclodextrins has plurality of functionalgroups that are negatively charged at physiological pH. Suitablepositively charged groups include, but are not limited to, quaternaryammonium groups. Exemplary cyclodextrins include, but are not limitedto, mono-6(A)-butylammonium-6(A)-deoxy-beta-cyclodextrin tosylate(BuAM-beta-CD) and Amine- and guanidine-derivatised β-cyclodextrin(βCD).

Preferably, the cyclodextrin is present in an amount of from about 0.1%to about 40% w/w of the overall formulation, preferably from about 5% toabout 40% w/w, more preferably about 10% to about 40% w/w, mostpreferably about 10% to about 35% w/w. In certain embodiments, theconcentration of the cyclodextrins is from about 15% to about 35% w/w,preferably from about 20% to about 35% w/w, more preferably about 30% toabout 35% w/w. In one embodiment, the formulation contains about 1 toabout 2, preferably about 1.5 mg neuroactive steroid (e.g.,pregnanolone, allopregnanolone, alphadalone, ganaxolone, alphaxolone)per mL of cyclodextrin, e.g., CAPTISOL®.

Pharmaceutical Compositions

In one aspect, the invention provides a pharmaceutical compositioncomprising a compound of the present invention (also referred to as the“active ingredient”) and a pharmaceutically acceptable excipient. Incertain embodiments, the pharmaceutical composition comprises aneffective amount of the active ingredient. In certain embodiments, thepharmaceutical composition comprises a therapeutically effective amountof the active ingredient. In certain embodiments, the pharmaceuticalcomposition comprises a prophylactically effective amount of the activeingredient.

The pharmaceutical compositions provided herein can be administered by avariety of routes including, but not limited to, oral (enteral)administration, parenteral (by injection) administration, rectaladministration, transdermal administration, intradermal administration,intrathecal administration, subcutaneous (SC) administration,intravenous (IV) administration, intramuscular (IM) administration, andintranasal administration.

Generally, the compounds provided herein are administered in aneffective amount. The amount of the compound actually administered willtypically be determined by a physician, in the light of the relevantcircumstances, including the condition to be treated, the chosen routeof administration, the actual compound administered, the age, weight,and response of the individual patient, the severity of the patient'ssymptoms, and the like.

When used to prevent the onset of a CNS-disorder, the compounds providedherein will be administered to a subject at risk for developing thecondition, typically on the advice and under the supervision of aphysician, at the dosage levels described above. Subjects at risk fordeveloping a particular condition generally include those that have afamily history of the condition, or those who have been identified bygenetic testing or screening to be particularly susceptible todeveloping the condition.

The pharmaceutical compositions provided herein can also be administeredchronically (“chronic administration”). Chronic administration refers toadministration of a compound or pharmaceutical composition thereof overan extended period of time, e.g., for example, over 3 months, 6 months,1 year, 2 years, 3 years, 5 years, etc, or may be continuedindefinitely, for example, for the rest of the subject's life. Incertain embodiments, the chronic administration is intended to provide aconstant level of the compound in the blood, e.g., within thetherapeutic window over the extended period of time.

The pharmaceutical compostions of the present invention may be furtherdelivered using a variety of dosing methods. For example, in certainembodiments, the pharmaceutical composition may be given as a bolus,e.g., in order to raise the concentration of the compound in the bloodto an effective level. The placement of the bolus dose depends on thesystemic levels of the active ingredient desired throughout the body,e.g., an intramuscular or subcutaneous bolus dose allows a slow releaseof the active ingredient, while a bolus delivered directly to the veins(e.g., through an W drip) allows a much faster delivery which quicklyraises the concentration of the active ingredient in the blood to aneffective level. In other embodiments, the pharmaceutical compositionmay be administered as a continuous infusion, e.g., by IV drip, toprovide maintenance of a steady-state concentration of the activeingredient in the subject's body. Furthermore, in still yet otherembodiments, the pharmaceutical composition may be administered as firstas a bolus dose, followed by continuous infusion.

The compositions for oral administration can take the form of bulkliquid solutions or suspensions, or bulk powders. More commonly,however, the compositions are presented in unit dosage forms tofacilitate accurate dosing. The term “unit dosage forms” refers tophysically discrete units suitable as unitary dosages for human subjectsand other mammals, each unit containing a predetermined quantity ofactive material calculated to produce the desired therapeutic effect, inassociation with a suitable pharmaceutical excipient. Typical unitdosage forms include prefilled, premeasured ampules or syringes of theliquid compositions or pills, tablets, capsules or the like in the caseof solid compositions. In such compositions, the compound is usually aminor component (from about 0.1 to about 50% by weight or preferablyfrom about 1 to about 40% by weight) with the remainder being variousvehicles or excipients and processing aids helpful for forming thedesired dosing form.

With oral dosing, one to five and especially two to four and typicallythree oral doses per day are representative regimens. Using these dosingpatterns, each dose provides from about 0.01 to about 20 mg/kg of thecompound provided herein, with preferred doses each providing from about0.1 to about 10 mg/kg, and especially about 1 to about 5 mg/kg.

Transdermal doses are generally selected to provide similar or lowerblood levels than are achieved using injection doses, generally in anamount ranging from about 0.01 to about 20% by weight, preferably fromabout 0.1 to about 20% by weight, preferably from about 0.1 to about 10%by weight, and more preferably from about 0.5 to about 15% by weight.

Injection dose levels range from about 0.1 mg/kg/hour to at least 20mg/kg/hour, all for from about 1 to about 120 hours and especially 24 to96 hours. A preloading bolus of from about 0.1 mg/kg to about 10 mg/kgor more may also be administered to achieve adequate steady statelevels. The maximum total dose is not expected to exceed about 5 g/dayfor a 40 to 80 kg human patient.

Liquid forms suitable for oral administration may include a suitableaqueous or nonaqueous vehicle with buffers, suspending and dispensingagents, colorants, flavors and the like. Solid forms may include, forexample, any of the following ingredients, or compounds of a similarnature: a binder such as microcrystalline cellulose, gum tragacanth orgelatin; an excipient such as starch or lactose, a disintegrating agentsuch as alginic acid, Primogel, or corn starch; a lubricant such asmagnesium stearate; a glidant such as colloidal silicon dioxide; asweetening agent such as sucrose or saccharin; or a flavoring agent suchas peppermint, methyl salicylate, or orange flavoring.

Injectable compositions are typically based upon injectable sterilesaline or phosphate-buffered saline or other injectable excipients knownin the art. As before, the active compound in such compositions istypically a minor component, often being from about 0.05 to 10% byweight with the remainder being the injectable excipient and the like.

Transdermal compositions are typically formulated as a topical ointmentor cream containing the active ingredient(s). When formulated as anointment, the active ingredients will typically be combined with eithera paraffinic or a water-miscible ointment base. Alternatively, theactive ingredients may be formulated in a cream with, for example anoil-in-water cream base. Such transdermal formulations are well-known inthe art and generally include additional ingredients to enhance thedermal penetration of stability of the active ingredients orformulation. All such known transdermal formulations and ingredients areincluded within the scope provided herein.

The compounds provided herein can also be administered by a transdermaldevice. Accordingly, transdermal administration can be accomplishedusing a patch either of the reservoir or porous membrane type, or of asolid matrix variety.

The above-described components for orally administrable, injectable ortopically administrable compositions are merely representative. Othermaterials as well as processing techniques and the like are set forth inPart 8 of Remington's Pharmaceutical Sciences, 17th edition, 1985, MackPublishing Company, Easton, Pennsylvania, which is incorporated hereinby reference.

The compounds of the present invention can also be administered insustained release forms or from sustained release drug delivery systems.A description of representative sustained release materials can be foundin Remington's Pharmaceutical Sciences.

The present invention also relates to the pharmaceutically acceptableacid addition salt of a compound of the present invention. The acidwhich may be used to prepare the pharmaceutically acceptable salt isthat which forms a non-toxic acid addition salt, i.e., a salt containingpharmacologically acceptable anions such as the hydrochloride,hydroiodide, hydrobromide, nitrate, sulfate, bisulfate, phosphate,acetate, lactate, citrate, tartrate, succinate, maleate, fumarate,benzoate, para-toluenesulfonate, and the like.

In another aspect, the invention provides a pharmaceutical compositioncomprising a compound of the present invention and a pharmaceuticallyacceptable excipient, e.g., a composition suitable for injection, suchas for intravenous (IV) administration.

Pharmaceutically acceptable excipients include any and all diluents orother liquid vehicles, dispersion or suspension aids, surface activeagents, isotonic agents, preservatives, lubricants and the like, assuited to the particular dosage form desired, e.g., injection. Generalconsiderations in the formulation and/or manufacture of pharmaceuticalcompositions agents can be found, for example, in Remington'sPharmaceutical Sciences, Sixteenth Edition, E. W. Martin (MackPublishing Co., Easton, Pa., 1980), and Remington: The Science andPractice of Pharmacy, 21^(st) Edition (Lippincott Williams & Wilkins,2005).

For example, injectable preparations, such as sterile injectable aqueoussuspensions, can be formulated according to the known art using suitabledispersing or wetting agents and suspending agents. Exemplary excipientsthat can be employed include, but are not limited to, water, sterilesaline or phosphate-buffered saline, or Ringer's solution.

In certain embodiments, the pharmaceutical composition further comprisesa cyclodextrin derivative. The most common cyclodextrins are α-, β- andγ-cyclodextrins consisting of 6, 7 and 8α-1,4-linked glucose units,respectively, optionally comprising one or more substituents on thelinked sugar moieties, which include, but are not limited to,substituted or unsubstituted methylated, hydroxyalkylated, acylated, andsulfoalkylether substitution. In certain embodiments, the cyclodextrinis a sulfoalkyl ether β-cyclodextrin, e.g., for example, sulfobutylether β-cyclodextrin, also known as Captisol®. See, e.g., U.S. Pat. No.5,376,645. In certain embodiments, the composition compriseshexapropyl-β-cyclodextrin. In a more particular embodiment, thecomposition comprises hexapropyl-β-cyclodextrin (10-50% in water).

The injectable composition can be sterilized, for example, by filtrationthrough a bacterial-retaining filter, or by incorporating sterilizingagents in the form of sterile solid compositions which can be dissolvedor dispersed in sterile water or other sterile injectable medium priorto use.

Generally, the compounds provided herein are administered in aneffective amount. The amount of the compound actually administered willtypically be determined by a physician, in the light of the relevantcircumstances, including the condition to be treated, the chosen routeof administration, the actual compound administered, the age, weight,response of the individual patient, the severity of the patient'ssymptoms, and the like.

The compositions are presented in unit dosage forms to facilitateaccurate dosing. The term “unit dosage forms” refers to physicallydiscrete units suitable as unitary dosages for human subjects and othermammals, each unit containing a predetermined quantity of activematerial calculated to produce the desired therapeutic effect, inassociation with a suitable pharmaceutical excipient. Typical unitdosage forms include pre-filled, pre-measured ampules or syringes of theliquid compositions. In such compositions, the compound is usually aminor component (from about 0.1% to about 50% by weight or preferablyfrom about 1% to about 40% by weight) with the remainder being variousvehicles or carriers and processing aids helpful for forming the desireddosing form.

The compounds provided herein can be administered as the sole activeagent, or they can be administered in combination with other activeagents. In one aspect, the present invention provides a combination of acompound of the present invention and another pharmacologically activeagent. Administration in combination can proceed by any techniqueapparent to those of skill in the art including, for example, separate,sequential, concurrent, and alternating administration.

Although the descriptions of pharmaceutical compositions provided hereinare principally directed to pharmaceutical compositions which aresuitable for administration to humans, it will be understood by theskilled artisan that such compositions are generally suitable foradministration to animals of all sorts. Modification of pharmaceuticalcompositions suitable for administration to humans in order to renderthe compositions suitable for administration to various animals is wellunderstood, and the ordinarily skilled veterinary pharmacologist candesign and/or perform such modification with ordinary experimentation.General considerations in the formulation and/or manufacture ofpharmaceutical compositions can be found, for example, in Remington: TheScience and Practice of Pharmacy 21^(st) ed., Lippincott Williams &Wilkins, 2005.

Buffers

The pharmaceutical compositions described herein (e.g., a pharmaceuticalcomposition formulated for parenteral injection) can comprise a buffer(e.g., a buffer at a pH of between about 3 and about 8 (e.g., betweenabout 5 and about 7, between about 5.5 and about 6.5, between about 5.9and about 6.1). As used herein, the terms “buffer,” “buffer system,” or“buffering component” refers to a compound that, usually in combinationwith at least one other compound, provides a chemical system in solutionthat exhibits buffering capacity, that is, the capacity to neutralize,within limits, the pH lowering or raising effects of either strong acidsor bases (alkali), respectively, with relatively little or no change inthe original pH (e.g., the pH before being affected by, e.g., strongacid or base). For example, a buffer described herein maintains orcontrols the pH of a solution to a certain pH range. For example,“buffering capacity” can refer to the millimoles (mM) of strong acid orbase (or respectively, hydrogen or hydroxide ions) required to changethe pH by one unit when added to one liter (a standard unit) of thebuffer solution. From this definition, it is apparent that the smallerthe pH change in a solution caused by the addition of a specifiedquantity of acid or alkali, the greater the buffer capacity of thesolution. See, for example, Remington: The Science and Practice ofPharmacy, Mack Publishing Co., Easton, Pennsylvania (19^(th) Edition,1995), Chapter 17, pages 225-227. The buffer capacity will depend on thekind and concentration of the buffer components.

According to some embodiments, the buffering components are present from1 mM, 2 mM, 5 mM, 10 mM, 20 mM, 50 mM, 75 mM, 100 mM, 150 mM, 200 mM,250 mM or more in solution.

Preferred buffers include 4-2-hydroxyethyl-1-piperazineethanesulfonicacid (HEPES), 2-{[tris(hydroxymethyl)methyl]amino}ethanesulfonic acid(TES), 3-(N-morpholino)propanesulfonic acid (MOPS),piperazine-N,N′-bis(2-ethanesulfonic acid) (PIPES), dimethylarsinic acid(cacodylate), citrate (e.g., saline sodium citrate, potassium citrate,ammonium citrate), 2-(N-morpholino)ethanesulfonic acid (MES), phosphate(e.g., PBS, D-PBS), succinate (i.e., 2(R)-2-(methylamino)succinic acid),acetate, dimethylglutarate, maleate, imidazole,N-(2-Acetamido)-2-aminoethanesulfonic acid (ACES),N,N-bis(2-hydroxyethyl)-2-aminoethanesulfonic acid (BES), Bicine,Bis-Tris, Borate, N-cyclohexyl-3-aminopropanesulfonic acid (CAPS),Glycine, 3-[4-(2-Hydroxyethyl)-1-piperazinyl]propanesulfonic acid (HEPPSor EPPS), N4-[Tris(hydroxymethyl)methyl]-3-aminopropanesulfonic acid,[(2-Hydroxy-1,1-bis(hydroxymethyl)ethyl)amino]-1-propanesulfonic acid(TAPS), Tricine, Tris, Tris Base, Tris Buffer, Tris-Glycine, Tris-HCl,collidine, veronal acetate, N-(2-Acetamido)iminodiacetic acid;N-(Carbamoylmethyl)iminodiacetic acid (ADA),β-Hydroxy-4-morpholinepropanesulfonic acid,3-Morpholino-2-hydroxypropanesulfonic acid (MOPSO), cholamine chloride,3-(N,N-Bis[2-(hydroxyethyl]amino)-2-hydroxypropanesulfonic acid (DIPSO),acetamidoglycine,3-{[1,3-Dihydroxy-2-(hydroxymethyl)-2-propanyl]amino}-2-hydroxy-1-propanesulfonicacid (TAPSO), Piperazine-N,N′-bis(2-hydroxypropanesulfonic acid)(POPSO), N-(2-Hydroxyethyl)piperazine-N′-(2-hydroxypropanesulfonic acid)(HEPPSO), N-cycloxhexyl-2-aminoethanesulfonic acid (CHES),2-amino-methyl-1,3-proponediol (AMPd), and glycinamide.

In some embodiments, the buffer comprises a monoprotic acid. In someembodiments, the buffer comprises a polyprotic acid (e.g., citrate orphosphate). In some embodiments, the buffer is a solution of one or moresubstances (e.g., a salt of a weak acid and a weak base; a mixture of aweak acid and a salt of the weak acid with a strong base). In someembodiments, the buffer comprises a piperazine (e.g., PIPES, HEPES,POPSO, EPPS).

In some embodiments, the buffer comprises a non-metal complexingcompound (e.g., MES, MOPS, PIPES).

In some embodiments, the buffer comprises a metal complexing compound(i.e., a metal chelating agent). In some embodiments, the metalchelating agent is citrate.

In some embodiments, the buffer is citrate buffer. In some embodiments,the buffer is phosphate buffer. In some embodiments, the buffer ishistidine buffer.

In some embodiments, the buffer is present at a concentration of about0.01, 0.05, 0.1, 0.5, 1, 5, 10, 20, 50, 100, 200, 250, 500 mM or more.In some embodiments, the buffer is present at a concentration of about 1to about 500 mM, about 1 to about 300 mM, about 1 to about 200 mM, about1 to about 100 mM, about 1 to about 50 mM, about 10 to about 500 mM,about 10 to about 300 mM, about 10 to about 200 mM, about 10 to about100 mM, about 10 to about 50 mM.

In some embodiments, the buffer is present at a concentration of about0.01 to about 10 mM, about 0.05 to about 5 mM, about 0.05 to about 5 mM,about 0.1 to about 5 mM, about 0.1 to about 3.5 mM.

In some embodiments, the pH of the aqueous solution is at or nearphysiological pH. Preferably, the pH of the aqueous solution is betweenabout 3 to about 8 (e.g., between about 5 and about 7, between about 5.5and about 6.5, between about 5.9 and about 6.1), or any specific valuewithin said range. In some embodiments, the pH of the aqueous solutionis between about 5 to about 6.5, or any specific value within said range(e.g., 5.5, 5.6, 5.7, 5.8, 5.9, 6, 6.1, 6.2, 6.3, 6.4). In someembodiments, the pH of the aqueous solution is about 6. The skilledartisan would recognize that the pH may be adjusted to a more optimal pHdepending on the stability of the neuroactive steroids andsulfoalkylether-β-cyclodextrin included in the solution. The pH can beadjusted, for example, with hydrochloric, phosphoric acid or organicacids, such as citric acid, lactic acid, malic acid, tartaric acid,acetic acid, gluconic acid, succinic acid, and combinations thereof. Insome embodiments, the pH is adjusted with base (e.g., 1 N sodiumhydroxide) or acid (e.g., 1 N hydrochloric acid).

In some embodiments, the buffer is citrate buffer and the pH is betweenabout 3 to about 8. In some embodiments, the buffer is citrate bufferand the pH is between about 3 to about 7.4. In some embodiments, thebuffer is citrate buffer and the pH is between about 5.5 to about 6.2.

In some embodiments, the buffer is phosphate buffer and the pH isbetween about 3 to about 9. In some embodiments, the buffer is phosphatebuffer and the pH is between about 6.2 to about 8.2. In someembodiments, the buffer is phosphate buffer and the pH is about 7.4.

Formulations for Administration, e.g., parenteral administration

Compounds (e.g., pregnanolone, allopregnanolone, alphadalone,ganaxolone, alphaxolone) described herein can be formulated forparenteral administration. Preferred doses, dosage forms, or modes ofadministration are parenteral, e.g., intranasally, buccally,intravenous, intramuscular, subcutaneous, intraparenteral, bucosal,sublingual, intraocular, and topical (e.g., intravenous orintramuscular). In another embodiment, the informational material caninclude instructions to administer the compound described herein to asuitable subject, e.g., a human, e.g., a human having or at risk for adisorder described herein. In some preferred embodiments, theneuroactive steroid is formulated for parenteral administration.

Parenteral formulations can be prepared as aqueous compositions usingtechniques known in the art. Typically, such compositions can beprepared as injectable formulations, for example, solutions orsuspensions; solid forms suitable for using to prepare solutions orsuspensions upon the addition of a reconstitution medium prior toinjection; emulsions, such as water-in-oil (w/o) emulsions, oil-in-water(o/w) emulsions, and microemulsions thereof, liposomes, or emulsomes.

In some embodiments, the parenteral formulations are prepared as aninjectable formulation, e.g., for intravenous administration. In someembodiments, the parenteral formulation comprises a compound (e.g., aneuroactive steroid as described herein, e.g., pregnanolone,allopregnanolone, alphadalone, ganaxolone, alphaxolone), and acyclodextrin, e.g., a β-cyclodextrin, e.g., a sulfo butyl etherβ-cyclodextrin, e.g., CAPTISOL®). In some embodiments, the parenteralformulation comprises pregnanolone, allopregnanolone, alphadalone,ganaxolone, or alphaxolone and a sulfo butyl ether β-cyclodextrin, e.g.,CAPTISOL®.

The carrier can be a solvent or dispersion medium containing orcomprising, for example, water (e.g., Water for Injection, USP),ethanol, one or more polyols (e.g., glycerol, propylene glycol, andliquid polyethylene glycol), oils, such as vegetable oils (e.g., peanutoil, corn oil, sesame oil, etc.), and combinations thereof.

The proper fluidity can be maintained, for example, by the use of acoating, such as lecithin, by the maintenance of the required particlesize in the case of dispersion and/or by the use of surfactants. In manycases, it will be preferable to include isotonic agents, for example,sugars or sodium chloride.

Solutions and dispersions of the active compounds as the free acid orbase or pharmacologically acceptable salts thereof can be prepared inwater or another solvent or dispersing medium suitably mixed with one ormore pharmaceutically acceptable excipients including, but not limitedto, surfactants, dispersants, emulsifiers, pH modifying agents, andcombination thereof.

Suitable surfactants may be anionic, cationic, amphoteric or nonionicsurface active agents. Suitable anionic surfactants include, but are notlimited to, those containing or comprising carboxylate, sulfonate andsulfate ions. Examples of anionic surfactants include sodium, potassium,ammonium of long chain alkyl sulfonates and alkyl aryl sulfonates suchas sodium dodecylbenzene sulfonate; dialkyl sodium sulfosuccinates, suchas sodium dodecylbenzene sulfonate; dialkyl sodium sulfosuccinates, suchas sodium bis-(2-ethylthioxyl)-sulfosuccinate; and alkyl sulfates suchas sodium lauryl sulfate. Cationic surfactants include, but are notlimited to, quaternary ammonium compounds such as benzalkonium chloride,benzethonium chloride, cetrimonium bromide, stearyl dimethylbenzylammonium chloride, polyoxyethylene and coconut amine. Examples ofnonionic surfactants include ethylene glycol monostearate, propyleneglycol myristate, glyceryl monostearate, glyceryl stearate,polyglyceryl-4-oleate, sorbitan acylate, sucrose acylate, PEG-150laurate, PEG-400 monolaurate, polyoxyethylene monolaurate, polysorbates,polyoxyethylene octylphenylether, PEG-1000 cetyl ether, polyoxyethylenetridecyl ether, polypropylene glycol butyl ether, Poloxamer® 401,stearoyl monoisopropanolamide, and polyoxyethylene hydrogenated tallowamide. Examples of amphoteric surfactants include sodiumN-dodecyl-β-alanine, sodium N-lauryl-β-iminodipropionate,myristoamphoacetate, lauryl betaine and lauryl sulfobetaine.

The formulation can contain a preservative to prevent the growth ofmicroorganisms. Suitable preservatives include, but are not limited to,parabens, chlorobutanol, phenol, sorbic acid, and thimerosal. Theformulation may also contain an antioxidant to prevent degradation ofthe active agent(s).

In some embodiments, a formulation is typically buffered to a pH of 3-9for parenteral administration upon reconstitution. Suitable buffersinclude, but are not limited to, phosphate buffers, acetate buffers,citrate buffers, or others described herein.

Water soluble polymers are often used in formulations for parenteraladministration. Suitable water-soluble polymers include, but are notlimited to, polyvinylpyrrolidone, dextran, carboxymethylcellulose, andpolyethylene glycol.

Sterile injectable solutions can be prepared by incorporating the activecompounds in the required amount in the appropriate solvent ordispersion medium with one or more of the excipients listed above, asrequired, followed by filtered sterilization. Generally, dispersions areprepared by incorporating the various sterilized active ingredients intoa sterile vehicle which contains the basic dispersion medium and therequired other ingredients from those listed above. In the case ofsterile powders for the preparation of sterile injectable solutions, thepreferred methods of preparation are vacuum-drying and freeze-dryingtechniques which yield a powder of the active ingredient plus anyadditional desired ingredient from a previously sterile-filteredsolution thereof. The powders can be prepared in such a manner that theparticles are porous in nature, which can increase dissolution of theparticles. Methods for making porous particles are well known in theart.

The parenteral formulations described herein can be formulated forcontrolled release including immediate release, delayed release,extended release, pulsatile release, and combinations thereof. In someembodiments, the neuroactive steroid is provided in a compositioncomprising a cyclodextrin, e.g., β-cyclodextrin, e.g., sulfo butyl etherβ-cyclodextrin, e.g., CAPTISOL®.

In some embodiments, the neuroactive steroid is provided at aconcentration of 0.1 to 10 mg/mL neuroactive steroid. In someembodiments, the neuroactive steroid is provided at a concentration of0.1, 0.5, 1, 1.25, 2.5, 3.75, 5, 6.25, 7.5, 8, 9, or 10 mg/mLneuroactive steroid. In some embodiments, the neuroactive steroid isprovided at a concentration of 1.25 mg/mL neuroactive steroid. In someembodiments, the neuroactive steroid is provided at a concentration of2.5 mg/mL neuroactive steroid. In some embodiments, the neuroactivesteroid is provided at a concentration of 3.75 mg/mL neuroactivesteroid. In some embodiments, the neuroactive steroid is provided at aconcentration of 5 mg/mL neuroactive steroid.

In some embodiments, the cyclodextrin is present in the composition at1-30%, 2-18%, 10-15% by weight of cyclodextrin per volume ofcomposition. In some embodiments, the cyclodextrin is present in thecomposition at 1, 2.5, 5, 10, 12, 13, 15, 25, or 30% by weight ofcyclodextrin per volume of composition. In some embodiments, thecyclodextrin is present in the composition at 12% by weight ofcyclodextrin per volume of composition. In some embodiments, thecyclodextrin is present in the composition at 25% by weight ofcyclodextrin per volume of composition.

In some embodiments, the cyclodextrin is present in the composition at1-30%, 2-18%, 10-15%, or 20-30% by weight of cyclodextrin per volume ofcomposition and the neuroactive steroid is provided at a concentrationof 0.1, 0.5, 1, 1.25, 2.5, 3.75, 5, 6.25, 7.5, 8, 9, or 10 mg/mLneuroactive steroid. In some embodiments, the cyclodextrin is present inthe composition at 1, 2.5, 5, 10, 12, 13, 15, 25, or 30% by weight ofcyclodextrin per volume of composition and the neuroactive steroid isprovided at a concentration of 0.1, 0.5, 1, 1.25, 2.5, 3.75, 5, 6.25,7.5, 8, 9, or 10 mg/mL neuroactive steroid. In some embodiments, thecyclodextrin is present in the composition at 12% by weight ofcyclodextrin per volume of composition and the neuroactive steroid isprovided at a concentration of 5 mg/mL neuroactive steroid. In someembodiments, the cyclodextrin is present in the composition at 25% byweight of cyclodextrin per volume of composition and the neuroactivesteroid is provided at a concentration of 5 mg/mL neuroactive steroid.In some embodiments, the cyclodextrin is present in the composition at12% by weight of cyclodextrin per volume of composition and theneuroactive steroid is provided at a concentration of 3.75 mg/mLneuroactive steroid. In some embodiments, the cyclodextrin is present inthe composition at 12% by weight of cyclodextrin per volume ofcomposition and the neuroactive steroid is provided at a concentrationof 2.5 mg/mL neuroactive steroid. In some embodiments, the cyclodextrinis present in the composition at 12% by weight of cyclodextrin pervolume of composition and the neuroactive steroid is provided at aconcentration of 1.25 mg/mL neuroactive steroid.

Dosage and Pharmacokinetics

The compositions described herein include a therapeutically effectiveamount of a neuroactive steroid, such as pregnanolone, allopregnanolone,alphadalone, ganaxolone, or alphaxolone; and a cyclodextrin, e.g., aβ-cyclodextrin, e.g., a sulfo butyl ether β-cyclodextrin, e.g.,CAPTISOL®) provided in a dosage form suitable for parenteraladministration. The compositions described herein include atherapeutically effective amount of a neuroactive steroid, such aspregnanolone, allopregnanolone, alphadalone, ganaxolone, or alphaxolone;and a cyclodextrin, e.g., a β-cyclodextrin, e.g., a sulfo butyl etherβ-cyclodextrin, e.g., CAPTISOL®) provided in a dosage form suitable fororal administration. In some embodiments, the neuroactive steroid isallopregnanolone. In some embodiments, the neuroactive steroid isdeuterated allopregnanolone. In some embodiments, the neuroactivesteroid is an estrol. In some embodiments, the neuroactive steroid isselected from neuroactive steroids that are disclosed in WIPOPublication Nos. WO2013/188792, WO 2013/056181, WO2015/010054,WO2014/169832, WO2014/169836, WO2014/169833, WO2014/169831,WO2015/027227, WO 2014/100228, U.S. Pat. Nos. 5,232,917, 8,575,375 and8,759,330.

Area under the curve (AUC) refers to the area under the curve thattracks the serum concentration (nmol/L) of neuroactive steroid over agiven time following the IV administration of the reference neuroactivesteroid standard. By “reference neuroactive steroid” is intended theformulation of neuroactive steroid that serves as the basis fordetermination of the total hourly neuroactive steroid dose to beadministered to a human subject with tremor (e.g., essential tremor),depression (e.g., postpartum depression), or an anxiety disorder toachieve the desired positive effect, i.e., a positive therapeuticresponse that is improved with respect to that observed withoutadministration of neuroactive steroid. In an embodiment, the dose ofneuroactive steroid to be administered provides a final serum level ofneuroactive steroid of about 100 ng/mL to about 1000 ng/mL, about 1100ng/mL to about 1450 ng/mL, 100 ng/mL to about 250 ng/mL, about 200 ng/mLto about 350 ng/mL, about 300 ng/mL to about 450 ng/mL, about 350 ng/mLto about 450 ng/mL, about 400 ng/mL to about 550 ng/mL, about 500 ng/mLto about 650 ng/mL, about 600 ng/mL to about 750 ng/mL, about 700 ng/mLto about 850 ng/mL, about 800 ng/mL to about 950 ng/mL, about 900 ng/mLto about 1050 ng/mL, about 1000 ng/mL to about 1150 ng/mL, about 100ng/mL to about 1250 ng/mL, about 1200 ng/mL to about 1350 ng/mL, about1300 ng/mL to about 1500 ng/m. In specific embodiments, the serum levelof neuroactive steroid is about 100 ng/mL, 250 ng/mL, 300 ng/mL, 350ng/mL, 360 ng/mL, 370 ng/mL, 380 ng/mL, 390 ng/mL, 400 ng/mL, 410 ng/mL,420 ng/mL, 430 ng/mL, 440 ng/mL, 450 ng/mL, 500 ng/mL, 750 ng/mL, 900ng/mL, 1200 ng/mL, 1400 ng/mL, or 1600 ng/mL.

In an embodiment, the dose of neuroactive steroid to be administeredprovides a final serum level of neuroactive steroid of about 100nmoles/L to about 5000 nmoles/L, about 100 nmoles/L to about 2500nmoles/L, about 100 nmoles/L to about 1000 nmoles/L, 100 nmoles/L toabout 500 nmoles/L, about 100 nmoles/L to about 250 nmoles/L, about 100nmoles/L to about 200 nmoles/L, about 125 nmoles/L to about 175nmoles/L. or about 140 nmoles/L to about 160 nmoles/L. In specificembodiments, the serum level of neuroactive steroid is about 100nmoles/L, 125 nmoles/L, 150 nmoles/L, 175 nmoles/L, 200 nmoles/L, 250nmoles/L, 300 nmoles/L, 350 nmoles/L, 500 nmoles/L, 750 nmoles/L, 1000nmoles/L, 1500 nmoles/L, 2000 nmoles/L, 2500 nmoles/L, or 5000 nmoles/L.

Provided herein are methods of administration, for example, of atherapeutic agent (e.g., a neuroactive steroid described herein) orcomposition comprising a therapeutic agent, to a subject, for example byIV infusion.

In an embodiment, the infusion occurs over at least 1, 2, 3, 4, 5, 6, or7 days. In an embodiment, the infusion occurs over the course of 1, 2,3, 4, 5, 6, or 7 days.

In an embodiment, the infusion is bolus infusion (e.g., single dose,single infusion). In an embodiment, the infusion is a plurality of bolusinfusions (e.g., multiple bolus infusions, e.g., more than one bolusinfusions, e.g., 2, 3, 4, 5 or more bolus infusions). In an embodiment,the plurality of bolus infusions is administered in 1 day, 2 days, 3days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 1 month, 2months, 3 months, 4 months, 5 months, 6 months or more. In anembodiment, the infusion is an intermittent infusion (e.g., an infusionthat occurs at irregular intervals). In an embodiment, the infusion is acontinuous infusion. In an embodiment, the method comprisesadministering a plurality of infusions. In an embodiment, the methodcomprises administering a first, second, and third infusion. In anembodiment, the administration of the second infusion begins no longerthan 90, 60, 30, 10, or 5 minutes after the beginning or end of theadministration of the first infusion. In an embodiment, the secondinfusion begins 0 to 90, 0 to 60, 0 to 30, 0 to 10, or 0 to 5 minutesafter the beginning or end of the administration of the first infusion.In an embodiment, the second infusion begins no more than 60, 30, 20,10, 5, 4, 3, 2, or 1 minute(s) after the end of administration of thefirst infusion. In an embodiment, the second infusion begins at the endof administration of the first infusion. In an embodiment, the firstinfusion and the initiation of the second infusion are performed withthe same delivery device, e.g., with the same cannula or reservoir.

In an embodiment, the amount of neuroactive steroid delivered/unit timevaries during the first infusion. In an embodiment, the first (step-up)infusion delivers a smaller amount of neuroactive steroid/unit time thanthe second (maintenance) infusion. In an embodiment, the first (step-up)infusion comprises administering a plurality of step doses, wherein eachsubsequent step dose delivers a larger amount of neuroactivesteroid/unit time than the step dose that precedes it.

In an embodiment, said third infusion is administered for a period oftime that is between 5 and 20 hours, 8 and 16 hours, 10 and 15 hours, or10 and 13 hours. In an embodiment, said first infusion is administeredfor 12+/−2 hours. In an embodiment, said first infusion is administeredfor 12 hours.

In an embodiment, the amount of neuroactive steroid delivered/unit timevaries during the first infusion.

In an embodiment, administering said step-up dose comprisesadministering a continuously increasing amount of neuroactive steroid ora composition comprising a neuroactive steroid. In an embodiment,administering said step-up dose comprises administering a continuouslyincreasing amount of neuroactive steroid/unit time.

In an embodiment, the method comprises a first, second, and third stepdose.

In an embodiment, said first step dose is administered at an amount ofneuroactive steroid/unit time of 5-50 μg/kg/hour (e.g., 21.5Kg/kg/hour). In an embodiment, said first step dose is administered atan amount of neuroactive steroid/unit time of 5-50 Kg/kg/hour, 10-40μg/kg/hour, 20-30 μg/kg/hour, 20 μg/kg/hour, 21 μg/kg/hour, 22Kg/kg/hour, or 21.5 Kg/kg/hour. In an embodiment, said first step doseis administered at an amount of neuroactive steroid/unit time of 30Kg/kg/hour. In an embodiment, said second step dose is administered atan amount of neuroactive steroid/unit time of 10-100 μg/kg/hour (e.g.,43 Kg/kg/hour). In an embodiment, said second step dose is administeredat an amount of neuroactive steroid/unit time of 10-100 μg/kg/hour,20-70 μg/kg/hour, 30-50 μg/kg/hour, 42 μg/kg/hour, 43 Kg/kg/hour, or 44Kg/kg/hour. In an embodiment, said second step dose is administered atan amount of neuroactive steroid/unit time of 60 Kg/kg/hour. In anembodiment, said third step dose is administered at an amount ofneuroactive steroid/unit time of 25-150 Kg/kg/hour. In an embodiment,said third step dose is administered at an amount of neuroactivesteroid/unit time of 25-150 Kg/kg/hour, 40-100 μg/kg/hour, 60-70μg/kg/hour, 63 μg/kg/hour, 64 Kg/kg/hour, 65 Kg/kg/hour, or 64.5Kg/kg/hour. In an embodiment, said third step dose is administered at anamount of neuroactive steroid/unit time of 90 Kg/kg/hour. In anembodiment, when the neuroactive steroid is allopregnanolone, a firststep dose, second step dose, and third step dose are administered byintermittent infusion, wherein said first step dose is administered atan amount of neuroactive steroid/unit time of 30 Kg/kg/hour, said secondstep dose is administered at an amount of neuroactive steroid/unit timeof 60 Kg/kg/hour, and said third step dose is administered at an amountof neuroactive steroid/unit time of 90 Kg/kg/hour. In an embodiment,when the neuroactive steroid is allopregnanolone, a first step dose andsecond step dose are administered by intermittent infusion, wherein saidfirst step dose is administered at an amount of neuroactive steroid/unittime of 30 Kg/kg/hour and said second step dose is administered at anamount of neuroactive steroid/unit time of 60 Kg/kg/hour.

In an embodiment, the third (step-down/downward taper) infusion deliversa smaller amount of neuroactive steroid/unit time than the second(maintenance) infusion. In an embodiment, the third (step-down/downwardtaper) infusion comprises administering a plurality of step doses,wherein each subsequent step dose delivers a lower amount of neuroactivesteroid/unit time than the step dose that precedes it. In an embodiment,said third infusion is administered for a period of time that is between5 and 20 hours, 8 and 16 hours, 10 and 15 hours, or 10 and 13 hours. Inan embodiment, said third infusion is administered for 12+/−2 hours. Inan embodiment, said third infusion is administered for 12 hours.

In an embodiment, administering said downward taper dose comprisesadministering a continuously decreasing amount of neuroactive steroid.In an embodiment, administering said downward taper dose comprisesadministering a continuously decreasing amount of neuroactivesteroid/unit time.

In an embodiment, the method comprises a first, second, and third stepdose.

In an embodiment, said first step dose is administered at an amount ofneuroactive steroid/unit time of 25-150 μg/kg/hour (e.g., 30Kg/kg/hour). In an embodiment, said first step dose is administered atan amount of neuroactive steroid/unit time of 25-150 Kg/kg/hour, 40-100μg/kg/hour, 60-70 μg/kg/hour, 63 Kg/kg/hour, 64 μg/kg/hour, 65Kg/kg/hour, or 64.5 Kg/kg/hour. In an embodiment, said second step doseis administered at an amount of neuroactive steroid/unit time of 10-100μg/kg/hour (e.g., 43 Kg/kg/hour). In an embodiment, said second stepdose is administered at an amount of neuroactive steroid/unit time of10-100 μg/kg/hour, 20-70 μg/kg/hour, 30-50 μg/kg/hour, 42 μg/kg/hour, 43Kg/kg/hour, or 44 Kg/kg/hour. In an embodiment, said third step dose isadministered at an amount of neuroactive steroid/unit time of 5-50Kg/kg/hour (e.g., 21.5 Kg/kg/hour). In an embodiment, said third stepdose is administered at an amount of neuroactive steroid/unit time of5-50 μg/kg/hour, 10-40 μg/kg/hour, 20-30 μg/kg/hour, 20 Kg/kg/hour, 21Kg/kg/hour, 22 Kg/kg/hour, or 21.5 μg/kg/hour.

In an embodiment, the method comprises administering asecond/maintenance infusion of 50-150 Kg/kg/hour (e.g., 86 Kg/kg/hour or60 Kg/kg/hour) of the neuroactive steroid. In an embodiment, thesecond/maintenance infusion is 50-150 μg/kg/hour, 60-100 μg/kg/hour,70-90 μg/kg/hour, 85 μg/kg/hour, 86 Kg/kg/hour, or 87 Kg/kg/hour. In anembodiment, said second/maintenance infusion is administered for aperiod of time that is between 5 and 80 hours, 10 and 70 hours, 20 and50 hours, or 30 and 40 hours. In an embodiment, said second/maintenanceinfusion is administered for 36+/−5 hours. In an embodiment, saidsecond/maintenance infusion is administered for 36 hours. In anembodiment, the plasma concentration of said second/maintenance infusionis measured at a preselected time, e.g., at 10, 15, 20, 30, 45, 60minutes, 2, 3, 4, 5, 6, 8, 10, 12, 24 hours, 2, 3, 4 days after theinitiation of said second/maintenance infusion. In an embodiment, saidsecond/maintenance infusion results in a plasma concentration of 150 nM,e.g., as measured at a preselected time, e.g., at 10, 15, 20, 30, 45, 60minutes, 2, 3, 4, 5, 6, 8, 10, 12, 24 hours, 2, 3, 4 days after theinitiation of said second/maintenance infusion. In an embodiment, saidsecond/maintenance infusion is administered at the same amount ofneuroactive steroid/unit time over the entire second/maintenanceinfusion.

In an embodiment, said first step dose is 10 to 40% (e.g., 25%) of thesecond/maintenance infusion; said second step dose is 30 to 70% (e.g.,50%) of the second/maintenance infusion; and said third step dose is 60to 90% (e.g., 75%) of the second/maintenance infusion. In an embodiment,said first step dose is 60 to 90% (e.g., 75%) of the second/maintenanceinfusion; said second step dose is 30 to 70% (e.g., 50%) of thesecond/maintenance infusion; and said third step dose is 10 to 40%(e.g., 25%) of the second/maintenance infusion. In an embodiment, theamount of neuroactive steroid delivered/unit time in said first stepdose is 10 to 40% (e.g., 25%) of the amount of neuroactive steroiddelivered/unit time in said second/maintenance infusion; the amount ofneuroactive steroid delivered/unit time in said second step dose is 30to 70% (e.g., 50%) of the amount of neuroactive steroid delivered/unittime in said second/maintenance infusion; and the amount of neuroactivesteroid delivered/unit time in said third step dose is 60 to 90% (e.g.,75%) of the amount of neuroactive steroid delivered/unit time in saidsecond/maintenance infusion. In an embodiment, the amount of neuroactivesteroid delivered/unit time in said first step dose is 60 to 90% (e.g.,75%) of the amount of neuroactive steroid delivered/unit time in saidsecond/maintenance infusion; the amount of neuroactive steroiddelivered/unit time in said second step dose is 30 to 70% (e.g., 50%) ofthe amount of neuroactive steroid delivered/unit time in saidsecond/maintenance infusion; and the amount of neuroactive steroiddelivered/unit time in said third step dose is 10 to 40% (e.g., 25%) ofthe amount of neuroactive steroid delivered/unit time in saidsecond/maintenance infusion.

EXAMPLES

In order that the invention described herein may be more fullyunderstood, the following examples are set forth. The synthetic andbiological examples described in this application are offered toillustrate the compounds, pharmaceutical compositions and methodsprovided herein and are not to be construed in any way as limiting theirscope. In some of the tables that follow (i.e., Table 10, Table 11,Table 12, Table 13, and Table 14), Compound 9 as described herein mayalso be named as “Formula I.”

Example 1. Nonclinical Studies with Compound 9

The GABAA positive allosteric modulator Compound 9, was orally active inpreclinical anticonvulsant models, and suppressed seizures arising froma variety of stimuli, including chemoconvulsants, proconvulsant stimuli,and genetic predisposition. Compound 9 caused sedation and ataxia asmanifestations of exaggerated pharmacology. The compound was assessed in14-day rat and dog toxicology studies with daily administration ofCompound 9 as a solution in HPBCD in dogs and Labrasol® in rats.

The NOAEL in rats was 3 mg/kg (females) and 22.5 mg/kg (males), and was2.5 mg/kg in dogs. There were no adverse effects in dogs or rats in themain toxicology studies. A single observation of mortality occurred inone female rat at the high dose in a toxicokinetic study which wassuspected to have been related to exaggerated pharmacology.

Example 2. A Phase I, Double-Blind, Placebo-Controlled, Single AscendingDose Study to Determine the Maximum Tolerated Dose (MTD),Pharmacokinetics and Pharmacodynamics of Compound 9 Oral Solution inHealthy Volunteers and the Safety, Tolerability, and Pharmacokinetics ofCompound 9 in Subjects with Essential Tremor Purpose

To determine the maximum tolerated dose (MTD) of Compound 9 OralSolution in healthy volunteers aged 18-55 years. In healthy volunteers:

-   -   To assess the safety and tolerability of Compound 9 Oral        Solution;    -   To assess the pharmacokinetic (PK) profile of single doses of        Compound 9 Oral Solution (with and without food);    -   To investigate plasma concentrations of Compound 9 metabolites        and urine concentrations of Compound 9;    -   To assess the pharmacodynamic effects of Compound 9 Oral        Solution MTD using EEG and psychomotor testing; In subjects with        Essential Tremor who are otherwise healthy:    -   To assess the safety, tolerability and pharmacokinetics (PK) of        Compound 9.

Materials and Methods

Compound 9 Oral Solution was prepared as 1 mg/mL and 6 mg/mL stockaqueous solutions of Compound 9 Drug Substance containing 40% HPBCD and0.0025% sucralose. The 1 mg/mL and 6 mg/mL stock Compound 9 OralSolutions were compounded from Compound 9 Drug Substance Powder in theBottle and Excipient(s) in the Bottle (manufactured under cGMPconditions) and further admixed at the clinical site in preparation fordosing. Placebo will be matched to study drug at each dose cohort.

Batch Formula for Stock Compound 9 Oral Solutions 1 mg/mL and 6 mg/mL

Subject doses will be prepared as an approximate 40 mL oral solution tobe swallowed all at once, followed by approximately 200 mL of water thathas been used to rinse the dosing bottle. The start time of swallowingthe approximate 40 mL oral solution is time zero for all assessments.

-   -   SAD Cohorts: In each of the SAD cohorts, subjects will be        randomly assigned to receive either Compound 9 (six subjects) or        placebo (two subjects) in a blinded manner. Cohort 1 will        receive Dose 1, Cohort 2 will receive Dose 2, and so on.    -   Food Cohort: After the Compound 9 single dose MTD has been        identified, subjects will be treated with a dose best        approximating 50% of the identified MTD in an open-label manner.    -   EEG Cohorts: After the single dose MTD has been determined, the        EEG cohort of subjects will be randomly assigned in a 1:1,        blinded manner to receive either Compound 9 oral solution at the        MTD or placebo OR the dose from the SAD best approximating 50%        MTD or placebo. Subjects will then return to the clinic        approximately one week later and cross over to the other        treatment within their cohort.    -   Essential Tremor Cohort: After the single dose MTD has been        determined, the Essential Tremor cohort will be assigned to        receive Compound 9 Oral Solution at a dose approximating the MTD        in an open-label manner.

The maximum recommended starting dose for this Phase I study is 0.25 mg.Doses will be prepared for each cohort based on the dose escalationscheme shown below which may be amended depending on Safety ReviewCommittee (SRC) dose escalation decisions described in the sectionbelow.

TABLE 1 Dose Escalation Scheme Maximum Formula Proposed (I) EscalationMaximum from Planned Actual Dose Previous Dose HPBCD Dose AdministeredCohort Cohort (mg) g (wt %) (mg) 1 N/A 0.25 0.113 (0.28%) 0.25 2 3x 0.750.343 (0.86%) 0.75 3 3x 2 0.910 (2.3%) 2 4 3x 6 0.460 (1.1%) 5.5 5 2x 120.910 (2.3%) 11 6 2x 24 1.83 (4.6%) 22 7 2x 48 3.66 (9.1%) 44 8 2x 967.31 (18.3%) 56 9 N/A N/A 4.19 (10.47%) 55 10 N/A 50% of 1.86 (4.6%) 22(Food) MTD 11A N/A 50% of 1.86 (4.6%) 22 (EEG) MTD 11B N/A MTD 4.19(10.47%) 55 (EEG) 12 N/A MTD 4.19 (10.47%) 55 (ET)

Study Design

This four-part study will assess the effects of a single dose ofCompound 9. The initial part of the study is a double-blind,placebo-controlled single ascending dose (SAD) design in healthy, adultvolunteers with the objective of identifying the maximum tolerated dose(MTD) and pharmacokinetic (PK) profiles of Compound 9 Oral Solution.Escalation to the next dose will be undertaken only after safety and PKdata have been reviewed by the Safety Review Committee (SRC) andagreement reached that it is safe to increase the dose. The SRC will notreceive any unblinded PK data unless it is agreed upon by the SRC tounblind a subject and/or cohort based on the completed safety review.

The second part of the study will assess food effect by observing the PKprofile of the single dose that best approximates 50% of the MTD afterconsumption of a standard meal in the same cohort that originally testedthis dose; this dose level may be adjusted for safety reasons.

In the third part of the study, the pharmacodynamic effects of Compound9 on the central nervous system (CNS) will be assessed in two cohorts offasted subjects using electroencephalograph (EEG) and other testingindicative of CNS effects. In one EEG cohort, subjects will receiveeither the MTD or placebo then return to the clinic to receive the othertreatment in crossover fashion. The second EEG cohort will receiveeither the dose that best approximates 50% of the MTD or placebo, andthen return to the clinic to receive the other treatment in crossoverfashion. The two EEG cohorts will have approximately one week betweencrossover periods.

After the single dose MTD has been identified, the fourth part of thestudy will assess the safety, tolerability and pharmacokinetics of asingle dose of Compound 9 in an open label fashion in one cohort of 6subjects with essential tremor who are otherwise healthy. Subjects willeat a standard clinic breakfast prior to dosing. Enrollment into thiscohort will continue until 6 subjects have been dosed.

The SAD and EEG cohorts will consist of eight subjects randomly assignedto active or placebo treatment. Sentinel dosing will be employed for thefirst SAD cohort, with one subject randomized to receive Compound 9 andthe other placebo on the first day. The other six subjects in the firstcohort will be dosed approximately 24 hours later. The food effectcohort will be comprised of up to six subjects, all of whom will receiveactive treatment. Sentinel dosing will be employed for the first cohort,with one subject randomized to receive Compound 9 and the other placeboon the first day. The other six subjects in the first cohort will bedosed approximately 24 hours later. Each cohort will be dosed atapproximately weekly intervals in order to allow adequate time forcollection and review of safety and PK data. The Essential Tremor cohortwill be comprised of 6 subjects assigned to receive a dose approximatingthe SAD MTD in an open-label fashion.

TABLE 2 Planned Dosing Scheme (Adjustments Possible by the Safety ReviewCommittee) Active Dose: Dose Dose Dose Dose Dose Dose Dose Dose DoseDose 1 2 3 4 5 6 7 8 9 “50” MTD Part 1 Cohort 1 6A 2P Cohort 2 6A 2PCohort 3 6A 2P Cohort 4 6A 2P Cohort 5 6A 2P Cohort 6 6A 2P Cohort 7 6A2P Cohort 8 6A 2P Cohort 9 6A 2P Part 2 Cohort 6A Food Part 3 Cohort4A:4P EEG-A X 4P:4A Cohort 4A:4P EEG-B X 4P:4A Part 4 Cohort 6AEssential Tremor Key: P = subjects on placebo; A = subjects on activetreatment with Compound 9 Dose “50” = the dose that best approximates50% of the MTD Cohort Food = the six subjects who previously receivedthe Dose “50” (or nearest dose) in a previous cohort Cohorts Food,EEG-A, EEG-B and Essential Tremor may be conducted concurrently.

Procedure Single Ascending Dose (SAD) and Determination of MTD

In each of the SAD cohorts, subjects will be randomly assigned toreceive either Compound 9 (six subjects) or placebo (two subjects) in ablinded manner. Cohort 1 will receive Dose 1, Cohort 2 will receive Dose2, and so on. With the exception of the Food cohort, study drug will beadministered in a fasting state (no food and only water for the previous12 hours) and a standard Phase I unit diet will be administeredbeginning approximately four to five hours after dosing. After thesentinel dosing scheme for the first cohort (two subjects administeredblinded study drug on the first day, one receiving Compound 9 and theother placebo, followed by the remainder of the subjects in the cohortadministered study drug approximately 24 hours later), all subjects ineach cohort will be administered study drug on the same dayapproximately one week apart to allow time for review of the safety,tolerability, and pharmacokinetic data by the SRC (SRC will not receiveunblinded PK data unless formal unblinding procedures are followed),which will determine whether it is acceptable for the dosing scheme tocontinue as planned. A detailed overview of assessments performed ateach visit for this part of the study is provided in the Schedule ofEvents (Table 6).

Food Effect

After the MTD has been identified, the effects of food on thepharmacokinetics, safety and tolerability of Compound 9 will bedetermined by having the subjects consume a standard Phase I unit mealfollowed by Compound 9 at the dose in the SAD that best approximates 50%of the Compound 9 MTD. The same six subjects who received activetreatment with Compound 9 Oral Solution at this dose in the SAD portionof the study will receive the same dose in the fed state. Subjects whohad received placebo at this dose will not be included in the foodeffect cohort. See the Schedule of Events (Table 6).

Pharmacodynamics (EEG and Psychomotor Testing)

The pharmacodynamic (PD) effects of the Compound 9 Oral Solution MTDwill be assessed via EEG, eye tracking, mood, psychomotor testing andsubjective drug effects. The dosing schedule for subjects participatingin the EEG portion of the study will be determined in the mannerdescribed below. Once the Compound 9 Oral Solution MTD has beendetermined, the last two cohorts of subjects will be randomly assignedin a blinded manner to receive treatments as shown in Table 2 (CohortsEEG-A and EEG-B, eight subjects in each cohort). Subjects in CohortEEG-A will be randomized to either the dose from the SAD that bestapproximates 50% of MTD or placebo and then crossover to the othertreatment after a one-week washout. Subjects in Cohort EEG-B will berandomized to either the MTD or placebo and then crossover to the othertreatment after a one-week washout. Subjects in this part of the studywill have continuous EEG collected for approximately 24 hours after thestart of dosing; standardized eye tracking and psychomotor tests willalso be performed (Table 8).

Essential Tremor

The safety, tolerability and pharmacokinetics of Compound 9 will beassessed in six subjects with essential tremor who are otherwisehealthy. All six subjects will be assigned to receive a doseapproximating the SAD MTD in an open-label manner (Table 9). Subjects inthis cohort will perform the clinician-rated TETRAS (Performancesubscale) and the accelerometer based Kinesia measure (Great LakesNeuroTechnologies, Valley View, OH) to generate exploratory tremoramplitude data which will be used to inform the design of possible Phase2 studies in essential tremor. Subjects in the Essential Tremor cohortwill be dosed after eating a standard breakfast.

Results

For all safety analyses of the SAD portion of the study, the placebodose group will be pooled across cohorts. AEs will be coded usingMedDRA™ with the version used specified in the clinical study report.The overall incidence of AEs will be displayed by System Organ Class(SOC), preferred term, dose group, and cohort. Incidence of AEs willalso be presented by maximum severity and relationship to study drug.Data from vital signs, clinical laboratory measures, ECG, and C-SSRSwill be summarized using descriptive statistics by dose group and cohort(where applicable).

Continuous endpoints will be summarized with n, mean, standarddeviation, median, minimum and maximum. In addition, change frombaseline values will be calculated at each time point and will besummarized using the same summary statistics. Out-of-range safetyendpoints may be categorized as low or high where applicable. For allcategorical endpoints, summaries will include counts and percentages.Derived PK parameters will include area under the plasma concentrationcurve (AUC0-inf), the distributional half-life and terminal half-life(t1/2), the maximum concentration (Cmax), the time to reach maximumconcentration (Tmax), and the clearance (CL) and urine excretion. PKparameters will be summarized using appropriate descriptive statistics.Time to reach maximum concentration (Tmax) will be summarized using n,mean, standard deviation, median, minimum, and maximum. All other PKparameters will be summarized using n, geometric mean, coefficient ofvariation, median, minimum, and maximum.

Dose proportionality will be analyzed using an ANCOVA model using thelogarithm of PK parameter (AUC and Cmax) as the dependent variable andthe logarithm of the dose as the independent variable. Point estimatesand the corresponding CIs will be estimated for both AUC and Cmax. Forthe food effect analysis, the log-transformed AUC and Cmax will becompared across food conditions using a paired t-test. Additionalstatistical testing may be performed according to the bioanalyticalstatistical analysis plan.

The pharmacodynamics analysis of EEG endpoints and their relationship topsychomotor testing and eye tracking measures will be described in aseparate analysis plan. In addition, PK/PD exploratory analyses will beperformed utilizing sedation, mood, EEG and psychomotor data. Thesecondary endpoints of SSS, MOAA/S, BL-VAS, and DEQ-5 values will besummarized using the same descriptive statistics described above for thesafety variables.

Subjects

Up to 94 subjects will be recruited into the study, depending on thenumber of cohorts studied; this includes 88 healthy subjects and 6subjects with essential tremor who are otherwise healthy. Subjects willbe replaced only if they withdraw/are withdrawn prior to study drugdosing. Note especially that subjects with essential tremor may fail toqualify on the TETRAS after Admission and be withdrawn from the studyprior to dosing. These subjects will be replaced to ensure there are 6subjects dosed in this cohort. Subjects will not be replaced if theywithdraw/are withdrawn prior to the second dose planned in the Foodcohort or one of the EEG or Essential Tremor cohorts.

Additional cohorts may be considered to accommodate dose repetition orslower dose escalation than planned in the SAD part of the study.Subjects participating in the double-blind, randomized portions of thestudy will be randomly assigned to either placebo or active treatmentwith Compound 9 Oral Solution according to a randomization scheduleprepared by an independent statistician. The Food cohort subjects willreceive study drug at the dose that best approximates 50% of the MTD inan open-label manner once MTD has been determined. The EEG cohortsubjects will initially receive either Compound 9

MTD or the dose that best approximates 50% of the MTD or placebo in a1:1, double-blind fashion and return for the crossover portion of thestudy to receive the other treatment for that cohort. The EssentialTremor cohort subjects will be assigned to receive a dose approximatingthe SAD MTD in an open-label manner.

Compound 9 Dosing Regimen

Subjects in each of the SAD cohorts will receive a single dose of studydrug, either Compound 9 Oral Solution (6 subjects) or placebo (2subjects). The proposed dose escalation scheme for the SAD part of thestudy is presented in Table 3. In the Food cohort, 6 subjects whoreceived the dose that best approximates 50% of the MTD will receivethis dose a second time after ingestion of a standard meal. In the EEGpart of the study, two cohorts of 8 subjects each will be tested usingtwo dosing periods.

One EEG cohort will receive the MTD; the other EEG cohort will receivethe dose that best approximates 50% of the MTD. During the first dosingperiod of each EEG cohort, subjects will receive either a single dose ofCompound 9 or matching placebo (4 subjects per active and placebotreatments). These subjects will return after an approximate one-weekwashout period to receive the MTD or placebo (Cohort EEG-A) OR the dosethat best approximates 50% of the MTD or placebo (Cohort EEG-B) withintheir cohort in crossover fashion. All 8 subjects will receive activetreatment in each of the two EEG cohorts during either the first orsecond dosing period. The appropriate dose of Compound 9 Oral Solutionor placebo will be administered according to the randomization scheduleavailable to the pharmacist. The dose escalation pattern may be modifiedby the Safety Review Committee.

Subjects in the Essential Tremor cohort will receive a single dose ofstudy drug with Compound 9 Oral Solution at a dose approximating the SADMTD in an open-label manner.

Doses will be prepared as an approximate 40 mL oral solution to beswallowed all at once, followed by approximately 200 mL of water whichhas been used to rinse the dosing bottle. The start time of swallowingthe approximately 40 mL oral solution is time zero for all assessments.Subjects in the Essential Tremor cohort may have assistance from theclinic staff when taking the study medication. Subjects in this cohortwill be dosed following consumption of a standard clinic breakfast.

TABLE 3 Proposed Dose Escalation Schedule for the SAD Part of the StudyMaximum Formula Proposed (I) Escalation Maximum from Planned Actual DosePrevious Dose HPBCD Dose Administered Cohort Cohort (mg) g (wt %) (mg) 1N/A 0.25 0.113 (0.28%) 0.25 2 3x 0.75 0.343 (0.86%) 0.75 3 3x 2ª 0.910(2.3%) 2 4 3x 6 0.460 (1.1%) 5.5 5 2x 12 0.910 (2.3%) 11 6 2x 24 1.83(4.6%) 22 7 2x 48 3.66 (9.1%) 44 8 2x 96 7.31 (18.3%) 66 9 N/A N/A 4.19(10.47%) 55 10 N/A 50% of 1.86 (4.6%) 22 (Food) MTD 11A N/A 50% of 1.86(4.6%) 22 (EEG) MTD 11B N/A MTD 4.19 (10.47%) 55 (EEG) 12 N/A MTD 4.19(10.47%) 55 (ET) Dose rounded for convenience of escalation

Dose Escalation and Stopping Rules (SAD Cohorts)

-   -   Serious Adverse Event: If any subject in a cohort has a serious        adverse event (SAE) that the SRC determines is related to        Compound 9, the SRC may stop the SAD phase of the study or may        permit ongoing dosing at lower doses of Compound 9 than that at        which the event occurred, depending on the nature of the event.    -   Severe Adverse Event: If three or more active treatment subjects        in a cohort have a severe adverse event that the safety        committee determines is related to Compound 9, the safety        committee may stop the SAD phase of the study or may permit        ongoing dosing at the same or lower doses of Compound 9,        depending on the nature of the event and the dose(s) at which        the events occurred.    -   MOAA/S Score: If at least one Compound 9-exposed subject within        a cohort has a MOAA/S score of two or less (≤2) at any time        point during normal waking hours (≥08:00 h to ≤22:00 h) and this        score is confirmed, i.e., repeat assessment is the same or        lower, or if two or more (≥2) Compound 9-exposed subjects have a        confirmed MOAA/S score of three or less (≤3) at any time point        during normal waking hours (≥08:00 h to ≤22:00 h) and this score        is confirmed, i.e., repeat assessment is the same or lower, dose        escalation to the next planned dose will not occur. Additional        dosing may be permitted by dosing Compound 9 at a lower dose or        by repeating the dose at which these events occurred depending        on the extent and duration of the sedation and the dose(s) at        which the sedation occurred. The Safety Review Committee will        consider MOAA/S scores as qualifying for stopping criteria only        when the confirmation score is equal to or lower than the first        assessment and when there is congruence with the SSS score at        the same time point.    -   If any of the following findings occur in at least two (2)        subjects exposed to Compound 9 Oral Solution within a cohort,        the SRC may not allow dose-escalation if at least two subjects        report the same finding. However, if each subject reported a        different finding, the SRC could allow dose escalation at lower        increments than planned. In all circumstances the SRC may allow        dose-repetition or dose reduction:        -   An increase from pre-dose in supine systolic blood pressure            of 60 mmHg sustained for at least five minutes, or a            decrease from pre-dose in supine systolic blood pressure of            30 mmHg sustained for at least five minutes, or supine            systolic blood pressure of ≤70 mmHg or ≥200 mmHg sustained            for at least five minutes;        -   An increase from pre-dose in supine diastolic blood pressure            of 40 mmHg sustained for at least five minutes, or a            decrease from pre-dose in supine diastolic blood pressure of            30 mmHg sustained for at least five minutes, or supine            diastolic blood pressure of ≤40 mmHg or ≥110 mmHg sustained            for at least five minutes;        -   An increase from pre-dose in supine heart rate of 50 bpm            sustained for at least five minutes, or a decrease from            pre-dose in supine heart rate of 30 bpm sustained for at            least five minutes, or supine heart rate of ≤45 bpm or ≥170            bpm sustained for at least five minutes;        -   QTc prolongation defined as QTcF increasing ≥60 msec and            persisting for at least 10 minutes or QTcF >500 msec and            persisting for at least 30 minutes;        -   A sustained increase in alanine aminotransferase (ALT) or            aspartate aminotransferase (AST) to >3× upper limit of            normal (ULN), which must be confirmed elevated >3×ULN within            48 hours;        -   Total bilirubin increase to >2×ULN confirmed on repeat            testing within 48 hours;        -   ALT or AST >2×ULN concurrent with total bilirubin >1.5×ULN            confirmed on repeat testing within 48 hours;        -   Serum creatinine >1.5×ULN confirmed on repeat testing within            48 hours;        -   Leukocyte count <2.5×109/L confirmed on repeat testing            within 48 hours;        -   Neutrophil count <1.0×109/L confirmed on repeat testing            within 48 hours;        -   Platelet count <100×109/L confirmed on repeat testing within            48 hours.        -   AUC and Cmax: based on the plasma concentration information            from previous cohorts, the SRC will consider adjusting the            dose (dose reduction, dose repetition, or reduced dose            escalation) for the next cohort if the Cmax of >50% of the            next cohort is expected to exceed 400 ng/mL (the estimated            human Cmax based on the lowest NOAEL Day 14 Cmax in female            rats). In addition, the SRC will not allow escalation to            doses beyond those predicted to result in an AUC above the            lowest NOAEL exposure in toxicology studies (male rat 14-day            toxicology, AUC 5,050 ng·h/mL).

Determination of Food-Effect Cohort Dose

The SRC will choose the dose for the food effect cohort based on thedoses that have been tolerated within the SAD phase; the dose bestapproximating 50% of the MTD will be utilized for the Food portion ofthe study.

Determination of Pharmacodynamic (PD)/EEG Cohort Dose

Two cohorts will be tested during the EEG phase of the study: one cohortwill receive the maximum tolerated dose (MTD) or placebo (EEG-A); theother cohort will receive the dose best approximating 50% of the MTD orplacebo (EEG-B). Each cohort will return in approximately one week tocross over to the other treatment within that cohort.

Determination of Essential Tremor Cohort Dose

Subjects in the Essential Tremor cohort will receive a single dose ofstudy drug of Compound 9 Oral Solution at the dose best approximatingthe SAD MTD.

Pharmacokinetic Criteria for Adjustment or Stopping Doses

During the SAD part of the study, the Sponsor PK lead will review theplasma PK data for the first 24 hours post-dose from each dose todetermine whether the results indicate a linear increase from theprevious dose that is proportionate to the increased dose and whetherthere are any indications of a compartment syndrome or threshold effect.The Sponsor PK lead will then provide feedback to the Sponsor StudyPhysician regarding the overall PK results, and the SRC will discussaccordingly. The SRC will not receive any unblinded PK data unless it isagreed upon by the SRC to unblind a subject and/or cohort based on thecompleted safety review for that cohort.

The SRC will not allow escalation of doses beyond those predicted toresult in an AUC above the lowest NOAEL exposure in toxicology studies(male rat 14-day toxicology, AUC 5,050 ng·h/mL). Based on the plasmaconcentration information from previous cohorts, the SRC will consideradjusting the dose (dose reduction, dose repetition, or reduced doseescalation) for the next cohort if the Cmax of >50% of the next cohortis expected to exceed 400 ng/mL (the estimated human Cmax based on thelowest NOAEL Day 14 Cmax in female rats).

Inclusion Criteria

-   -   Signed informed consent before any study-specific procedures are        performed;    -   Non-nicotine or tobacco using, healthy ambulatory male and        female subjects ≥18 to <55 years of age at the time of        screening, with no history or evidence of clinically relevant        medical disorders as determined by the investigator, who will        consult with the physician if there are questions about        eligibility.    -   Bodyweight ≥60 kg and body mass index (BMI) ≥18.0 and ≤30.0        kg/m2 at screening visit.    -   Physical and neurological examination, clinical laboratory        values (one repeat test allowed), vital signs (normal ranges per        the Investigator, one repeat allowed), and electrocardiograms        (ECGs) are clinically acceptable to the investigator and        Sponsor.    -   Male subjects must agree to practice an acceptable method of        effective birth control while on study, and for 13 weeks after        receiving the dose of study drug. Effective methods of birth        control include sexual abstinence; vasectomy; or a condom with        spermicide (men) in combination with female partner's method,        e.g. hormonal birth control, or intrauterine device. Female        subjects must be non-childbearing capacity, e.g. postmenopausal        (at least 12 months since last menstruation) or surgically        sterile (tubal ligation, bilateral oophorectomy, or        hysterectomy).    -   Males must be willing to abstain from sperm donation while on        study through 13 weeks after receiving the dose of study drug.        Amended for Essential Tremor cohort (must meet above criteria        except where amended as indicated)    -   Diagnosis of Essential Tremor in subjects who are otherwise        healthy, with upper limb symptoms clearly present as confirmed        by a TETRAS upper limb total score of ≥8 at the Admission visit;    -   Tremor present for at least three years prior to screening as        confirmed by the treating neurologist;    -   Male or female, ≥18 to ≤75 years of age;    -   Physical and neurological examination, clinical laboratory        values, vital signs (normal ranges per the Investigator), and        electrocardiograms (ECGs) are clinically acceptable.

Exclusion Criteria

-   -   Clinically significant abnormal values for hematology, clinical        chemistry or urinalysis at the screening and admission visits.        Abnormalities considered to be non-clinically significant by the        investigator are acceptable.    -   Subject with history of suicidal behavior within two years or        who has answered YES to questions 3, 4 or 5 on the C-SSRS at the        Screening or Day −1 visits, or is currently at risk of suicide        in the opinion of the investigator.    -   Clinically significant abnormal physical examination OR 12-lead        electrocardiogram (ECG) at the screening or admission visits.        NOTE: QTc(F) interval of >450 msec in males or >470 msec in        females, will be the basis for exclusion from the study. ECG may        be repeated for confirmatory purposes if initial values obtained        exceed the limits specified.    -   Significant history and/or presence of hepatic, renal,        cardiovascular, pulmonary, gastrointestinal, hematological,        immunologic, ophthalmologic, metabolic or oncological disease.    -   History or presence of psychiatric or neurologic disease or        condition (including but not limited to epilepsy, closed head        trauma with clinically significant sequelae, partial onset        seizures, eating disorders, etc.); the diagnosis of Essential        Tremor is not an exclusion for subjects in the Essential Tremor        cohort.    -   Alcohol and Drug Use/Abuse:        -   Subjects in the SAD, Food and EEG parts of the study are            excluded if they have a recent history (within previous 6            months) of alcohol or drug abuse (as judged by the            Investigator), or has consumed >2 alcohol drinks/day during            the last 3 months prior to screening (1 glass is            approximately equivalent to: beer [284 mL], wine [125 mL/4            ounces], or distilled spirits [25 mL/1 ounce]). Subjects            that consume 3 glasses of alcoholic beverages per day but            less than 14 glasses per week may be enrolled at the            discretion of the investigator. Positive screens for alcohol            or controlled substances at the screening or admission            visits will disqualify a subject from study participation.        -   Subjects in the Essential Tremor cohort are excluded if            there is a recent history (within the previous 6 months) of            alcohol or drug abuse (as judged by the Investigator); there            are no amounts specified for alcohol consumption for this            cohort as it is understood that subjects may be            self-medicating with alcohol. A positive result for alcohol            or controlled substances at the screening or admission            visits will disqualify a subject from study participation.    -   Tobacco Use:        -   Subjects in the SAD, Food and EEG parts of the study are            excluded if they currently use or have regularly used            tobacco or tobacco-containing products (cigarettes, pipes,            etc.) for at least one month prior to screening OR positive            urine cotinine screen (>400 ng/mL) at the screening or            admission visits.        -   Subjects in the Essential Tremor cohort may be tobacco users            and may have a positive urine cotinine screen at the            screening or admission visit.    -   Any subject with a history, presence and/or current evidence of        serologic positive results for hepatitis B surface antigen,        hepatitis C antibodies, or HIV antibodies 1 and 2.    -   Donation of one or more units of blood or acute loss of an        equivalent amount of blood within 60 days prior to dosing (one        unit=450 mL).    -   Any subject who has received treatment with an investigational        drug or device that has not received regulatory approval during        the 30 days, or 5 half-lives of the investigational drug,        whichever is longer, prior to study drug administration.    -   Medications:        -   Subjects in the SAD, Food and EEG parts of the study are            excluded if they use or have used any prescription or            over-thecounter medication, herbal medication, vitamins, or            mineral supplements within 14 days prior to administration            of the study drug. Acetaminophen up to 3 g per day will be            allowed.        -   Subjects in the Essential Tremor cohort must stop using any            medications at least 48 hours or a minimum of 5 half-lives            (whichever is longer) prior to study drug administration and            they may not take medications sooner than 48 hours after            study drug administration, unless approved by the Sponsor            Study Physician during the Screening Period. Acetaminophen            up to 3 g per day will be allowed as will medications            prescribed by the study physician while the subject is            confined to the unit.        -   Use of agents known to affect drug metabolism: use of any            known CYP450 inhibitors and/or inducers within the 14 days            or 5 halflives (whichever is longer) or consumed grapefruit            juice, grapefruit, Seville oranges or St John's Wort or            products containing these within 30 days prior to receiving            the first dose of study drug.    -   Any subject who consumes excessive amounts of caffeine, defined        as greater than 6 servings (1 serving is approximately        equivalent to 120 mg of caffeine) of coffee, tea, cola, or other        caffeinated beverages per day within 30 days prior to admission.    -   Any subject with previous exposure to the study drug or who is        known to be allergic to Compound 9 or any of its excipients,        including its major excipient HPBCD.    -   Investigative site personnel or their immediate families        (spouse, parent, child or sibling whether biological or legally        adopted).    -   Any subject unwilling or unable to comply with study procedures.

Treatment

Subjects participating in the double-blind, randomized portions of thestudy will be randomly assigned to either placebo or active treatmentwith Compound 9 Oral Solution according to a randomization scheduleprepared by an independent statistician. The Food cohort subjects willreceive study drug at the dose that best approximates 50% of the MTD inan open-label manner once MTD has been determined. The EEG cohortsubjects will initially receive either Compound 9 (MTD or the dose thatbest approximates 50% of the MTD) or placebo in a 1:1, double-blindfashion and return for the crossover portion of the study to receive theother treatment for that cohort. Subjects in each of the SAD cohortswill receive a single dose of study drug, either Compound 9 OralSolution (6 subjects) or placebo (2 subjects).

In the Food cohort, 6 subjects who received the dose that bestapproximates 50% of the MTD will receive this dose a second time afteringestion of a standard meal. In the EEG part of the study, two cohortsof 8 subjects each will be tested using two dosing periods. One EEGcohort will receive the MTD; the other EEG cohort will receive the dosethat best approximates 50% of the MTD.

During the first dosing period of each EEG cohort, subjects will receiveeither a single dose of Compound 9 or matching placebo (4 subjects peractive and placebo treatments). These subjects will return after anapproximate one week washout period to receive the MTD or placebo(Cohort EEG-A) OR the dose that best approximates 50% of the MTD orplacebo (Cohort EEG-B) within their cohort in crossover fashion. All 8subjects will receive active treatment in each of the two EEG cohortsduring either the first or second dosing period.

In the Essential Tremor cohort, 6 subjects will receive a single dose ofCompound 9 Oral Solution at the dose best approximating the SAD MTD.Subjects will be dosed after a standard clinic breakfast. Note thatsubjects with essential tremor may fail to qualify on the TETRAS afterAdmission and be withdrawn from the study prior to dosing. Thesesubjects will be replaced to ensure there are 6 subjects dosed in thiscohort.

The appropriate dose of Compound 9 Oral Solution or placebo will beadministered according to the randomization schedule available to thepharmacist. The dose escalation pattern may be modified by the SafetyReview Committee.

Procedures/Measurements

The SAD cohorts will consist of up to 6 visits over a period of up to 28days prior to dosing and 14 days after dosing.

The Food Effect cohort will consist of 9 visits over a period of up to28 days prior to dosing and 21 days after initial dosing. This cohortwill be administered a repeat of the dose that best approximates 50% ofthe MTD.

The EEG cohorts will consist of 9 visits over a period of up to 28 daysprior to dosing and 21 days after initial dosing.

The Essential Tremor cohort will consist of up to 5 visits over a periodof up to 28 days prior to dosing and approximately 14 days after dosing.

During each phase of the study, subjects will be admitted to the unitapproximately 24 hours prior to the expected time of dosing. During theSAD part of the study, subjects will be confined to the unit forapproximately 72 hours after each dose. For the Food effect part of thestudy, subjects will be confined to the unit for approximately 48 hoursafter dosing; subjects may be released sooner if it is predicted thatplasma concentrations of drug will be below the level of quantificationearlier than 48 hours after dosing. During the EEG portion of the study,subjects will be confined to the unit for approximately 36 hours oruntil the plasma concentration of drug is predicted to be below thelevel of quantification. Subjects in the Essential Tremor cohort areconfined to the unit for 24 hours after dosing.

No subject may be discharged from the unit until the investigator issatisfied that they have no continuing adverse events that could berelated to study drug.

Physical examinations, vital signs, laboratory assessments andobservations by experienced Phase I personnel will be undertakenthroughout the study based on the Schedules of Events for all cohorts.The Stanford Sleepiness Scale (SSS) and Modified Observer's Assessmentof Alertness/Sedation Scale (MOAA/S) will be used to assess sedationeffects. The Bond-Lader VAS will assess different aspects ofself-reported mood; the Drug Effects Questionnaire (DEQ-5) will assesswhether the subject “liked” the drug and/or felt “high”. Psychomotortesting will be undertaken during the EEG cohorts to assess cognitivefunction in a variety of domains such as attention, working memory,episodic secondary memory, executive function, and motor skills. Areduced battery of cognitive tests will be applied to subjects in theSAD cohorts.

An EEG with at least 24 channels set for continuous recording will beapplied two hours prior to dosing and kept in place for approximately 36hours after dosing in the EEG phase only. Five-minute relaxation epochswill be conducted during the 36 hours as follows: V2 and V5: −20 to −15minutes before dosing; post-dose 60 (+1 hour) to 65 minutes; 120 (2hours) to 125 minutes; 420 (7 hours) to 425 minutes; 1,380 to 1,385minutes (23 hours) after dosing. A relaxation epoch may be added or thetiming of the relaxation epochs adjusted based on Tmax or other findingsobserved during the SAD part of the study.

Eye tracking will be assessed for the EEG cohorts only.

Dose Adjustment Criteria for the SAD Cohorts

A Safety Review Committee (SRC) will be established comprised of thePrincipal Investigator, the Sponsor Study Physician and the CRO DrugSafety Physician. Designees may be utilized consistent with the SRCCharter. Optional attendees may participate as required. The roles andresponsibilities of the SRC will be described in a SRC Charter whichwill be agreed and signed prior to the first dose of study drug beingadministered. The role of the SRC is to assess the safety, tolerabilityand pharmacokinetic information collected for each dose level anddetermine that the next cohort should:

-   -   advance to the next planned dose level;    -   advance to a dose lower than the next planned dose level; or    -   repeat the previous dose level.

In addition, the SRC may stop the study for safety reasons at any timeand will determine when the MTD has been reached using the pre-definedstopping rules. The committee may overrule these stopping criteria bybeing more conservative, i.e., next dose lower than planned, but may notrule that the next dose should be higher than planned. The SRC will notreceive any unblinded PK data unless it is agreed upon by the SRC tounblind a subject and/or cohort based on the completed safety review.

Dose Escalation and Stopping Rules for the SAD Cohorts

-   -   Serious Adverse Event: If any subject in a cohort has a serious        adverse event (SAE) that the SRC determines is related to        Compound 9, the SRC may stop the SAD phase of the study or may        permit ongoing dosing at lower doses of Compound 9 than that at        which the event occurred, depending on the nature of the event.    -   Severe Adverse Event: If three or more active treatment subjects        in a cohort have a severe adverse event that the safety        committee determines is related to Compound 9, the safety        committee may stop the SAD phase of the study or may permit        ongoing dosing at the same or lower doses of Compound 9,        depending on the nature of the event and the dose(s) at which        the events occurred.    -   MOAA/S Score: If at least one Compound 9-exposed subject within        a cohort has a MOAA/S score of two or less (≤2) at anytime point        during normal waking hours (≥08:00 h to ≤22:00 h) and this score        is confirmed, i.e., repeat assessment is the same or lower, or        if two or more (≥2) Compound 9-exposed subjects have a confirmed        MOAA/S score of three or less (≤3) at any time point during        normal waking hours (≥08:00 h to ≤22:00 h) and this score is        confirmed, i.e., repeat assessment is the same or lower, dose        escalation to the next planned dose will not occur. Additional        dosing may be permitted by dosing Compound 9 at a lower dose or        by repeating the dose at which these events occurred depending        on the extent and duration of the sedation and the dose(s) at        which the sedation occurred. The Safety Review Committee will        consider MOAA/S scores as qualifying for stopping criteria only        when the confirmation score is equal to or lower than the first        assessment and when there is congruence with the SSS score at        the same time point.    -   If any of the following findings occur in at least two (2)        subjects exposed to Compound 9 Oral Solution within a cohort,        the SRC may not allow dose-escalation if at least two subjects        report the same finding. However, if each subject reported a        different finding, the SRC could allow dose escalation at lower        doses than planned. In all circumstances the SRC may allow        dose-repetition or dose reduction:    -   An increase from pre-dose in supine systolic blood pressure of        60 mmHg sustained for at least five minutes, or a decrease from        pre-dose in supine systolic blood pressure of 30 mmHg sustained        for at least five minutes, or supine systolic blood pressure of        ≤70 mmHg or ≥200 mmHg sustained for at least five minutes;    -   An increase from pre-dose in supine diastolic blood pressure of        40 mmHg sustained for at least five minutes, or a decrease from        pre-dose in supine diastolic blood pressure of 30 mmHg sustained        for at least five minutes, or supine diastolic blood pressure of        ≤40 mmHg or ≥110 mmHg sustained for at least five minutes;    -   An increase from pre-dose in supine heart rate of 50 bpm        sustained for at least five minutes, or a decrease from pre-dose        in supine heart rate of 30 bpm sustained for at least five        minutes, or supine heart rate of ≤45 bpm or ≥170 bpm sustained        for at least five minutes;    -   QTc prolongation defined as QTcF increasing ≥60 msec and        persisting for at least 10 minutes or QTcF >500 msec and        persisting for at least 30 minutes;    -   A sustained increase in alanine aminotransferase (ALT) or        aspartate aminotransferase (AST) to >3× upper limit of normal        (ULN), which must be confirmed elevated >3×ULN within 48 hours;    -   Total bilirubin increase to >2×ULN confirmed on repeat testing        within 48 hours;    -   ALT or AST >2×ULN concurrent with total bilirubin >1.5×ULN        confirmed on repeat testing within 48 hours;    -   Serum creatinine >1.5×ULN confirmed on repeat testing within 48        hours;    -   Leukocyte count <2.5×109/L confirmed on repeat testing within 48        hours;    -   Neutrophil count <1.0×109/L confirmed on repeat testing within        48 hours;    -   Platelet count <100×109/L confirmed on repeat testing within 48        hours.    -   AUC and Cmax: based on the plasma concentration information from        previous cohorts, the SRC will consider adjusting the dose (dose        reduction, dose repetition, or reduced dose escalation) for the        next cohort if the Cmax of >50% of the next cohort is expected        to exceed 400 ng/mL (the estimated human Cmax based on the        lowest NOAEL Day 14 Cmax in female rats). In addition, the SRC        will not allow escalation to doses beyond those predicted to        result in an AUC above the lowest NOAEL exposure in toxicology        studies (male rat 14-day toxicology, AUC 5,050 ng·h/mL).

Pharmacokinetic Assessments

Pharmacokinetic blood samples will be taken and processed for analysisfor concentrations of Compound 9. Selected samples may also be analyzedfor concentrations of Compound 9 metabolites; urine samples will also betested for concentrations of Compound 9.

Blood Sample Collection

Plasma samples for PK analysis will be collected according to thesampling collection times specified in Table 4 for the SAD, Food andEssential Tremor cohorts and Table 5 for the EEG cohorts. The start timeof study drug administration is time zero and all postdosing samplingtimes are relative to this time. The Investigator or designee willarrange to have the plasma samples transported as directed forbioanalysis.

Selected samples may also be analyzed for concentrations of metabolitesof Compound 9.

An additional PK sample may be collected at any time if clinicallyindicated and at the discretion of the Investigator (e.g. for unusual orsevere AEs). Each sample will be marked with unique identifiers with atleast the study number, subject number, and the nominal sample time. Thedate and actual time that the blood sample was taken will be recorded onthe case report form or equivalent.

Urine Sample Collection

During the SAD phase only, all voided urine will be collected and pooledover the following time periods: pre-dose; 0-4 hours; 4-8 hours; 8-12hours; 12-24 hours; 24-36 hours; 36-48 hours. A sample will be obtainedfrom each pooled sample and processed for analysis of Compound 9concentrations. Samples may be collected for Compound 9 metaboliteconcentrations. The predose urine sample is to be collected just priorto dosing. The post-dose collection periods are relative to dosing. Ifthe planned time point is between the hours of ≥22.00 h and ≤08.00 heach day or if the subject has been discharged before the +72 hour timepoint during the Food, EEG and Essential Tremor phases of the study, theassessment need not be conducted at that time point.

Storage and Shipment of Pharmacokinetic and Urine Samples

The plasma and urine samples should be kept frozen at approximately −70to −80° C. until analyzed. They should be packed as directed to avoidbreakage during transit and with sufficient dry ice to prevent thawingfor at least 72 hours. A specimen-identification form or equivalent mustbe completed and sent to the laboratory with each set of samples. Theclinical site will arrange to have the plasma and urine samplestransported as directed for bioanalysis as detailed in the PKinstructions.

Sample Analysis

Bioanalysis of plasma samples for the determination of Compound 9 levelswill be conducted utilizing a validated LC-MS/MS method at AgiluxLaboratories, Worcester, MA. The methodology for urine bioanalysis is indevelopment and will be conducted at a later time by Agilux using thestored samples.

The following lists the laboratory testing that will be done at theappropriate time points:

-   -   Hematology: basophils with differential, eosinophils with        differential, lymphocytes with differential, monocytes with        differential, neutrophils with differential, reticulocytes,        hemoglobin, hematocrit, platelets, red blood cell count, white        blood cell count.    -   Biochemistry, renal: glucose, calcium, phosphorus, blood urea        nitrogen, creatinine, sodium, potassium, chloride, bicarbonate.    -   Biochemistry, hepatic: albumin, ALT, AST, total bilirubin,        direct bilirubin, indirect bilirubin, alkaline phosphatase,        total protein, lactate dehydrogenase, GGT.    -   Other: triglycerides, activated partial thromboplastin time        (APTT), prothrombin time, INR, HBsAG, antiHCV antibodies, HIV-1        and -2 antibodies.    -   Urinalysis: protein, glucose, pH, blood, leukocytes;        urobilinogen; bilirubin, ketones, nitrite.    -   Other: FSH and serum pregnancy test will be tested during        Screening.

Taste Assessment

At approximately one hour after each dose, subjects will be asked tocomplete a 100 mm visual analogue scale where 0 is “the worst tastingliquid I have ever swallowed” and 100 is “the nicest tasting liquid Ihave ever swallowed”. Subjects will be asked to describe the taste ofthe medication (using words such as “bitter” or “sweet”). The TasteAssessment scale is provided in Appendix 11.

12-Lead Electrocardiogram (ECG)

A supine 12-lead ECG will be performed at the times specified below andthe standard intervals recorded as well as any abnormalities. The12-lead ECG will be assessed at SAD V1 (Screening and Day −1[Admission]), SAD V5, Food V1 and V8, EEG V1 and EEG V8. All time pointsare relative to the time of dosing. If the ECG planned time point isbetween the hours of ≥22.00 h and ≤08.00 h each day or if the subjecthas been discharged before the +72 hour time point during the Food andEEG phases of the study, the assessment need not be conducted at thattime point.

-   -   SAD Cohorts: V1 Admission; post-dose 1, 2, 4, 8, 12, 24, 36, 48,        and 72 hours.    -   Food Cohort: V1 Admission; V5 pre dose and post-dose 1, 2, 4, 8,        12, 24, 36; V7 48 and 72 hours.    -   EEG Cohorts: V2 through V7—pre-dose; post-dose 1, 2, 4, 8, 12,        24, 36, 48 and 72 hours after dosing.    -   Essential Tremor Cohort: V1 (Screening and Day −1 [Admission]);        V2—pre-dose; post-dose 4, 8, 24 hours; V3-48 h after dosing; V4.

Pulse Oximetry

Continuous pulse oximetry will be recorded at the same time points asthe vital signs in all cohorts beginning 30 minutes prior to dosing andcontinuing for the first 24 h post dose. A pulse oximetry reading willalso be taken at V1 (Screening). Continuous pulse oximetry will not becancelled during the sleeping hours and will continue to be collected atall scheduled time points.

Continuous ECG (cECG)

Continuous ECG monitoring will be conducted from approximately 1 hourpre-dose up to the last assessment time point on discharge days;subjects will have continuous ECG monitoring (telemetry) in order todetect any cardiac rhythm abnormalities. Any such clinically significant

Columbia-Suicide Severity Rating Scale (C-SSRS)

The “Baseline/Screening” C-SSRS form will be completed during theAdmission visit (lifetime history and past 24 months). The “Since LastVisit” C-SSRS form will be completed at all subsequent scheduled timepoints as detailed below. The C-SSRS is provided in Appendix 4.

-   -   SAD Cohorts: V1 (Day −1 [Admission]); V2 pre-dose, V4 post-dose        72 h, and V5.    -   Food Cohort: V1 (Day −1 Admission for Food cohort); V7 post-dose        72 h, and V8.    -   EEG Cohorts: V1 (Day −1 [Admission]); V4 post-dose 72 h, V5        (crossover) pre-dose, V7 post-dose 72 h, and V8.    -   Essential Tremor Cohort: Baseline/Screening test: V1 (Day −1        [Admission]); Since Last Visit test: V2 post-dose 24 h; V3        post-dose 48 h; V4.

Stanford Sleepiness Scale (SSS)

The SSS will be administered at the time points shown below for eachcohort. All time points are relative to the time of dosing. If theplanned time point is between the hours of ≥22.00 h and ≤08.00 h eachday or if the subject has been discharged before the +72 hour time pointduring the Food and EEG phases of the study, the assessment need not beconducted at that time point. The SSS is provided in Appendix 5. The SSSshould be performed prior to the MOAA/S score.

-   -   SAD Cohorts: V2—pre-dose and post-dose 1, 2, 3, 4, 5, 6, 7, 8,        10, 12, 14, 16, 22, and 24 hours; V3—post-dose 28, 32, 36, 40        and 48 hours; V4—post-dose 60 and 72 hours.    -   Food Cohort: V5—pre-dose and post-dose 1, 2, 3, 4, 5, 6, 7, 8,        10, 12, 14, 16, 22 and 24 hours; V6—post-dose 28, 32, 36, 40,        and 48 hours; V7—post-dose 60 and 72 hours.    -   EEG Cohorts: V2—pre-dose and post-dose 2, 4, 6, 8, 10, 12, 14,        16, and 24 hours; V3—post-dose 36 and 48 hours; V4—post-dose 60        and 72 hours; V5 (crossover)—pre-dose and post-dose 2, 4, 6, 8,        10, 12, 14, 16, and 24 hours; V6—post-dose 36 and 48 hours;        V7—post-dose 60 and 72 hours.    -   Essential Tremor Cohort: V2—pre-dose and post-dose 2, 4, 6, 8,        10, 12, 14, 16 and 24 hours; V3—post-dose 48 hours; V4.

Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S)

The MOAA/S allows exploration of deeper sedation states than the SSS.The MOAA/S will be administered at the time points shown below for eachcohort. All time points are relative to the time of dosing. If theplanned time point is between the hours of ≥22.00 h and ≤08.00 h eachday or if the subject has been discharged before the +72 hour time pointduring the Food and EEG phases of the study, the assessment need not beconducted at that time point. If a MOAA/S score of 3 or less (≤3) isobserved, confirm the score by waiting approximately 10 minutes andreadministering the MOAA/S assessment. Record both the scheduled andunscheduled assessments.

All time points relate to the administration of study drug.

-   -   SAD Cohorts: V2—pre-dose and post dose, 1, 2, 3, 4, 5, 6, 7, 8,        10, 12, 14, 16, 22 and 24 hours; V3—post-dose 28, 32, 36, 40 and        48 hours; V4—post-dose 60 and 72 hours.    -   Food Cohort: V5—pre-dose and post-dose, 1, 2, 3, 4, 5, 6, 7, 8,        10, 12, 14, 16, 22 and 24 hours; V6—post-dose 28, 32, 36, 40 and        48 hours; V7—post-dose 60 and 72 hours.    -   EEG Cohorts: V2—pre-dose and post-dose, 2, 4, 6, 8, 10, 12, 14,        16, and 24 hours; V3—post-dose 36 and 48 hours; V4—post-dose 60        and 72 hours; V5 (crossover)—pre-dose and post-dose 2, 4, 6, 8,        10, 12, 14, 16 and 24 hours; V6—post-dose 36 and 48 hours;        V7—post-dose 60 and 72 hours.    -   Essential Tremor Cohort: V2—pre-dose and post-dose 2, 4, 6, 8,        10, 12, 14, 16 and 24 hours; V3—post-dose 48 hours; V4.

Bond-Lader VAS (Mood Rating Scale) (BL-VAS)

Mood will be assessed using the Bond-Lader Mood Rating Scale during theEEG and Essential Tremor cohorts only. This is a 16-partself-administered questionnaire that employs 100 mm visual analoguescales to explore different aspects of self-reported mood. If theplanned time point is between the hours of ≥22.00 h and ≤08.00 h eachday or if the subject has been discharged before the +72 hour time pointduring the Food and EEG phases of the study, the assessment need not beconducted at that time point. The BL-VAS is provided in Appendix 7.

The mood scale will be administered at the following time points:EEG: V2—pre-dose and post-dose 2, 12 and 24 hours; V3—post-dose 36 and48 hours; V4—postdose 72 hours; V5 (crossover)—pre-dose and post-dose 2,12 and 24 hours after dosing; V6—postdose 36 and 48 hours; V7—post-dose72 hours; V8.

-   -   Essential Tremor Cohort: V2—pre-dose and post-dose 2, 12 and 24        hours.

Drug Effects Questionnaire (DEQ-5)

A Drug Effects Questionnaire (DEQ-5) will be administered as follows:

-   -   1. Do you FEEL a drug effect right now?    -   2. Are you HIGH right now?    -   3. Do you DISLIKE any of the effects that you are feeling right        now?    -   4. Do you LIKE any of the effects that you are feeling right        now?    -   5. Would you like MORE of the drug you took, right now?        The answers are recorded on a 100 mm visual analogue scale with        the answer for each being “Not at all” and “Extremely” at the        extremes. There will be options to record “Not applicable” for        questions 3 and 4 if no drug effects are felt and for question 5        prior to administration of study medication.        If the planned time point is between the hours of ≥22.00 h and        ≤08.00 h each day or if the subject has been discharged before        the +72 hour time point during the Food and EEG phases of the        study, the assessment need not be conducted at that time point.        The DEQ5 will be administered at the following time points in        all cohorts except the Food cohort:    -   SAD Cohorts: V2—pre-dose and post-dose 2, 4, 12 and 24 hours.    -   EEG Cohorts: V2—pre-dose and post-dose 2, 4, 12 and 24 hours;        V3—post-dose 36 and 48 hours;    -   V4—post-dose 72 hours; V5 (crossover)—pre-dose and post-dose 2,        12 and 24 hours; V6—postdose 36 and 48 hours; V7—post-dose 72.    -   Essential Tremor Cohort: V2—pre-dose and post-dose 2, 4, 12 and        24 hours.    -   The DEQ-5 is provided in Appendix 8.

Psychomotor Testing

Psychomotor tests will be conducted to assess cognitive function in avariety of domains such as attention, working memory, episodic secondarymemory, executive function, and motor skills. If the planned time pointis between the hours of ≥22.00 h and ≤08.00 h each day or if the subjecthas been discharged before the +72 hour time point during the Food andEEG phases of the study, the assessment need not be conducted at thattime point.

SAD Cohorts: V2—pre-dose and post-dose 3, 8 and 24 hours. A reducedbattery of cognitive tests will be applied to subjects in the SADcohorts. EEG Cohorts: V2—pre-dose and post-dose 3, 8 and 24 hours afterdosing; V3 post-dose 48 hours; V4—post-dose 72 hours; V5(crossover)—pre-dose and post-dose 3, 8 and 24 hours; V6—post-dose 48hours; V7—post-dose 72 hours. Subjects will complete a practice sessionat admission on Day −1 or at any time prior to the first scheduled timepoint.

EEG

For the EEG cohorts only, an EEG with a minimum of 24 channels set forcontinuous recording will be applied approximately two hours prior todosing and kept in place for approximately 36 hours after dosing.Five-minute relaxation epochs will be conducted at the time pointslisted below. During these epochs subjects are asked to close theireyes, relax and empty their minds of thoughts. If the relaxation epochis scheduled at the same time as another assessment, the relaxationepoch takes precedence. If a PK sample is due, the sample should betaken just prior to beginning the relaxation epoch. EEG relaxationepochs: A five-minute relaxation epoch will be undertaken at V2 and V5:−20 to −15 minutes before dosing; post-dose 60 (+1 hour) to 65 minutes;120 (+2 hours) to 125 minutes (+2 hours); 420 (+7 hours) to 425 minutes;1,380 to 1,385 minutes (+23 hours) after dosing. A relaxation epoch maybe added or the timing of the relaxation epochs adjusted based on Tmaxor other findings observed during the SAD part of the study.

Eye Tracking

For the EEG cohorts only, eye tracking will be assessed at the followingtime points. If the planned time point is between the hours of ≥22.00 hand ≤08.00 h each day or if the subject has been discharged before the+72 hour time point during the Food and EEG phases of the study, theassessment need not be conducted at that time point.

EEG Cohorts: V2 and V5—pre-dose and post-dose 2.5, 7.5, 9.5 and 23.5hours.

Kinesia (Accelerometer-Based) and TETRAS

For the Essential Tremor cohort, the TRG Essential Tremor RatingAssessment Scale (TETRAS) performance subscale (Appendix 12) and theaccelerometer-based Kinesia assessments will be administered at the timepoints shown below. Note that the TETRAS score for the test conductedduring Visit 1 (Admission) will be used to determine eligibility andmust be ≥8. The testing performed at Visit 2 just prior to dosing willnot disqualify the subject even if any result is <8.

Dosing should occur as soon as possible after completing the thirdpre-dose TETRAS.Essential Tremor Cohort Kinesia and TETRAS Testing: V1—Admission(determines eligibility); V2—pre-dose—three tests separated by at least30 minutes; V2 post-dose 1, 2, 4, 6, 8, 12 and 24 hours after dosing.

Adverse and Serious Adverse Events Adverse Event (AE)

An AE is the development of an undesirable medical condition or thedeterioration of a pre-existing medical condition following or duringexposure to a pharmaceutical product, whether or not considered casuallyrelated to the product. In clinical studies, an AE can include anundesirable medical condition occurring at any time, including baselineor washout periods, even if no study treatment has been administered.

All AEs that occur after any subject has been enrolled, beforetreatment, during treatment, or within 14 days following the cessationof treatment, whether or not they are related to the study, must berecorded on forms provided by designee.

Serious Adverse Event (SAE)

A serious adverse event is an AE occurring during any study phase (i.e.,baseline, treatment, washout, or follow-up), and at any dose of theinvestigational product, comparator or placebo, that fulfils one or moreof the following:

-   -   Results in death    -   It is immediately life-threatening    -   It requires in-patient hospitalization or prolongation of        existing hospitalization    -   It results in persistent or significant disability or incapacity    -   Results in a congenital abnormality or birth defect    -   It is an important medical event that may jeopardize the subject        or may require medical intervention to prevent one of the        outcomes listed above.

Recording Sedation as an Adverse Event

Sedation will be assessed using specific rating scales in this study. Inorder to apply consistency to adverse event reports of sedation,Investigators will not record sedation as an adverse event unless thereis a score of ≥5 on the SSS and/or a score of ≤2 on the MOAA/S.Consideration should be given to the most appropriate term to describethe sedation characteristics.

Relationship to Study Drug

An Investigator who is qualified in medicine must make the determinationof relationship to the investigational product for each AE (Unrelated,Possibly Related or Probably Related). The Investigator should decidewhether, in his or her medical judgment, there is a reasonablepossibility that the event may have been caused by the investigationalproduct. If no valid reason exists for suggesting a relationship, thenthe AE should be classified as “unrelated.” If there is any validreason, even if undetermined, for suspecting a possible cause-and-effectrelationship between the investigational product and the occurrence ofthe AE, then the AE should be considered “related.”

-   -   Not Related: No relationship between the experience and the        administration of study drug; related to other etiologies such        as concomitant medications or subject's clinical state.    -   Possibly Related: A reaction that follows a plausible temporal        sequence from administration of the study drug and follows a        known response pattern to the suspected study drug. The reaction        might have been produced by the subject's clinical state or        other modes of therapy administered to the subject, but this is        not known for sure.    -   Probably Related: A reaction that follows a plausible temporal        sequence from administration of the study drug and follows a        known response pattern to the suspected study drug. The reaction        cannot be reasonably explained by the known characteristics of        the subject's clinical state or other modes of therapy        administered to the subject. If the relationship between the        AE/SAE and the investigational product is determined to be        “possible” or “probable” the event will be considered to be        related to the investigational product for the purposes of        expedited regulatory reporting.

Recording Adverse Events

Adverse events spontaneously reported by the subject and/or in responseto an open question from the study personnel or revealed by observationwill be recorded during the study at the investigational site.Clinically significant changes in laboratory values, blood pressure, andpulse need not be reported as AEs unless they prompt corrective medicalaction by the investigator, constitute an SAE or lead to discontinuationof administration of study drug.

Information about AEs will be collected from the signing of the consentform until the final visit of the study for that subject. Adverse eventsthat occur after the first administration of study drug will be denotedTreatment Emergent Adverse Events. All AEs will be followed until theyare resolved or have reached a clinical plateau with no expectation offuture change.

The AE term should be reported in standard medical terminology whenpossible. For each AE, the investigator will evaluate and report theonset (date and time), resolution or clinical plateau (date and time),intensity, causality, action taken, serious outcome (if applicable), andwhether or not it caused the subject to discontinue the study.

Intensity will be assessed according to the following scale:

-   -   Mild (awareness of sign or symptom, but easily tolerated)    -   Moderate (discomfort sufficient to cause interference with        normal activities)    -   Severe (incapacitating, with inability to perform normal        activities)

Reporting Serious Adverse Events

All SAEs (related and unrelated) will be recorded from the signing ofthe consent form until 28 days following the last dose of study drug.Any SAEs considered possibly or probably related to the investigationalproduct and discovered by the Investigator at any time after the studyshould be reported. All SAEs must be reported to the Sponsor orSponsor's designee immediately or as soon as possible, but no later than6 hours by phone and in writing within 24 hours of the first awarenessof the event. The Investigator must complete, sign and date the SAEpages, verify the accuracy of the information recorded on the SAE pageswith the corresponding source documents to Designee.

Safety Analysis

For all safety analyses of the SAD portion of the study, the placebodose group will be pooled across cohorts. AEs will be coded usingMedDRA™ with the version used specified in the clinical study report.The overall incidence of AEs will be displayed by System Organ Class(SOC), preferred term, dose group, and cohort. Incidence of AEs willalso be presented by maximum severity and relationship to study drug.Data from vital signs, clinical laboratory measures, ECG, and C-SSRSwill be summarized using descriptive statistics by dose group andcohort, where applicable. Continuous endpoints will be summarized withn, mean, standard deviation, median, minimum and maximum. In addition,change from baseline values will be calculated at each time point andwill be summarized using the same summary statistics. Out-of-rangesafety endpoints may be categorized as low or high, where applicable.For all categorical endpoints, summaries will include counts andpercentages.

Pharmacokinetic Analysis

Derived PK parameters will include area under the plasma concentrationcurve (AUC0-inf), the distributional half-life and terminal half-life(t½), the maximum concentration (Cmax), the time to reach maximumconcentration (Tmax), and the clearance (CL) and urine excretion. PKparameters will be summarized using appropriate descriptive statistics.Time to reach maximum concentration (Tmax) will be summarized using n,mean, standard deviation, median, minimum, and maximum.

All other PK parameters will be summarized using n, geometric mean,coefficient of variation, median, minimum, and maximum.

Dose proportionality will be analyzed using an ANCOVA model using thelogarithm of PK parameter (AUC and Cmax) as the dependent variable andthe logarithm of the dose as the independent variable. Point estimatesand the corresponding CIs will be estimated for both AUC and Cmax.

Food Effect Analysis

For the food effect analysis, the log-transformed AUC and Cmax will becompared across food conditions using a paired t-test. Additionalstatistical testing may be performed according to the bioanalyticalstatistical analysis plan.

Other Endpoint Analyses

The secondary endpoints of SSS, MOAA/S, BL-VAS, and DEQ-5 values will besummarized using the same descriptive statistics described above for thesafety variables. The pharmacodynamics analysis of EEG endpoints andtheir relationship to psychomotor testing and eye tracking measures willbe described in a separate analysis plan. In addition, PK/PD exploratoryanalyses will be performed utilizing sedation, mood, EEG and psychomotordata. For the Essential Tremor cohort, the exploratory endpoints of theTRG Essential Tremor Rating

Assessment Scale (TETRAS) performance subscale and accelerometer-basedKinesia scores will be summarized as described for safety and secondaryendpoints.

Statistical Considerations

The Safety Population is defined as all subjects who are administeredstudy drug. The Pharmacokinetic (PK) Population is defined as allsubjects who are administered Compound 9 and have at least onebioanalysis result for the plasma concentration of Compound 9.

No formal sample size calculations have been undertaken for this safetyand tolerability study. The number of subjects in each cohort and ateach dose level is thought to be sufficient to assess preliminary safetyand tolerability following single doses of Compound 9. No efficacyparameters are being collected or analyzed for this Phase I study.

For all safety analyses of the SAD portion of the study, the placebodose group will be pooled across cohorts. AEs will be coded usingMedDRA™ with the version used specified in the clinical study report.The overall incidence of AEs will be displayed by System Organ Class(SOC), preferred term, dose group, and cohort. Incidence of AEs willalso be presented by maximum severity and relationship to study drug.Data from vital signs, clinical laboratory measures, ECG, and C-SSRSwill be summarized using descriptive statistics by dose group andcohort, where applicable. Continuous endpoints will be summarized withn, mean, standard deviation, median, minimum and maximum. In addition,change from baseline values will be calculated at each time point andwill be summarized using the same summary statistics. Out-of-rangesafety endpoints may be categorized as low or high, where applicable.For all categorical endpoints, summaries will include counts andpercentages. PK parameters will be summarized using appropriatedescriptive statistics.

Time to reach maximum concentration (Tmax) will be summarized using n,mean, standard deviation, median, minimum, and maximum. All other PKparameters will be summarized using n, geometric mean, coefficient ofvariation, median, minimum, and maximum.

Dose proportionality will be analyzed using an ANCOVA model using thelogarithm of PK parameter (AUC and Cmax) as the dependent variable andthe logarithm of the dose as the independent variable. Point estimatesand the corresponding CIs will be estimated for both AUC and Cmax.For the food effect analysis, the log-transformed AUC and Cmax will becompared across food conditions using a paired t-test. Additionalstatistical testing may be performed according to the bioanalyticalstatistical analysis plan.

The secondary endpoints of SSS, MOAA/S, BL-VAS, and DEQ-5 values will besummarized using the same descriptive statistics described above for thesafety variables. The pharmacodynamics analysis of EEG endpoints andtheir relationship to psychomotor testing and eye tracking measures willbe described in a separate analysis plan. In addition, PK/PD exploratoryanalyses will be performed utilizing sedation, mood, EEG and psychomotordata.

Pharmacokinetic Exemplary Schedule

TABLE 4 SAD, Food Effect and Essential Tremor Cohorts - all samplingtimes in hours relative to dosing Visit 2 for SAD and EssentialTremor/Visit 5 for Food-Effect Pre-Dose 0.25 0.5 1 1.5 2 2.5 3 3.5 4 4.55 5.5 6 7 8 10 12 16 24

The Following Additional Time Point is to be Collected for the EssentialTremor Cohort:

Visit 3 48

The following additional time point is to be collected for the SAD andFood Effect cohorts:

Visit 3/Visit 6 28 32 36 48

TABLE 5 EEG Cohort - all sampling times in hours relative to dosingVisit Visit 2 and Visit 5 for PD/EEG* 3/6 Pre-Dose 2 2.5 3 6 7.5 8 9 9.523 23.5 24 36 *Blood samples for plasma concentrations of Compound 9should be taken just prior to any scheduled relaxation epoch

TABLE 6 Schedule of Events SAD Cohorts Visit V1 V2 V3 V4 V5 V6 VisitWindow D −28 0 +24 h +48 h V2 + 7 d V2 + 14 d to D −1 to +24 h to +48 hto +72 h (±1 d) (±1 d) Visit Days Screen D 1 D 2 D 3 Follow Up End ofStudy Informed Consent X Inclusion/Exclusion X Demographics X MedicalHistory X Physical Examination X X Body Weight/Height X CBC/SerumChemistry¹ X X X X Urinalysis¹ X X X X Drug/Alcohol Screen¹⁰ X XHepatitis & HIV Screen X Genetic Sample X Vital Signs² X X X X X Pulseoximetry X X 12-Lead ECG³ X X X X X cECG X X X C-SSRS⁴ X X X X SSS⁵ X XX MOAA/S⁶ X X X DEQ5⁷ X Psychomotor Testing⁸ X Plasma PK Samples⁹ X XUrine PK Samples X X Confined to Unit X X X Administer Study Drug XTaste Assessment X Adverse Events¹¹ X X X X X X Concomitant Meds¹¹ X X XX X X Study Completion X ¹Screening and Safety Laboratory Tests SADCohorts: V1 (Screening and Day −1 [Admission]); V2 pre-dose; V4 72 hpost-dose; V5 ²Vital Signs SAD Cohorts: V1 (Screening and Day −1[Admission]), V2 pre-dose and post-dose 15, 30, 60, 90, and 120 minutes,and 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 7, 8, 10, 12, 14, 16, 22, and 24hours; V3 - post-dose 28, 32, 36, and 48 hours after dosing, V4 - 60 and72 hours after dosing; V5. ³12-Lead ECG SAD Cohorts V1: V1 Screening andDay −1 (Admission), pre-dose and post-dose 1, 2, 4, 8, 12, 24, 36, 48,and 72 hours. ⁴C-SSRS SAD Cohorts: Screening and Day −1 (admission), V4post-dose 72 h, and V5. ⁵SSS SAD Cohorts: V2 - pre-dose and post-dose 1,2, 3, 4, 5, 6, 7, 8, 10, 12, 14, 16, 22, and 24; V3 - post-dose 28, 32,36, 40 and 48 hours; V4 - post-dose 60 and 72 hours. ⁶MOAA/S SADCohorts: V2 - pre-dose and post-dose 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 14,16, 22, and 24; V3 - post-dose 28, 32, 36, 40 and 48 hours; V4 -post-dose 60 and 72 hours. ⁷DEQ5 SAD Cohorts: V2 - pre-dose and postdose 2, 12 and 24 hours. ⁸Psychomotor testing SAD Cohorts: V2 - pre-doseand post-dose 3, 8 and 24 hours. Subjects will complete a practicesession during Screening prior to their Day −1 (Admission) assessment.⁹See Appendix 2 ¹⁰Urine drug screen and alcohol breathalyzer will beconducted at Visit 1 during Screening and Day −1 (Admission) ¹¹AdverseEvents and concomitant medications (new or changed) will be collectedduring Visit 1 at both Screening and Day −1 (Admission) in addition tothe other time points noted in the Schedule of Events.

TABLE 7 Schedule of Events Food Cohort Note that subjects will havealready completed the SAD portion of the study and are returning for the“fed” part of the study; Screening assessments completed prior toadmission for the SAD portion do not need to be repeated even if morethan 28 days have elapsed prior to the “V1 Admission for Food cohort”visit. Visit V1 Admission V5 V6 V7 V8 V9 for Food Food Food Food FollowUp End Study Visit Window V5 + 24 h V5 + 48 h V5 + 7 d V5 + 14 d D −1 0to +24 h to +48 h to +72 h (±1 d) (±1 d) Inclusion/Exclusion X PhysicalExamination X X Body Weight/Height X CBC/Serum Chemistry¹ X X XUrinalysis X X X Drug/Alcohol Screen X Vital Signs² X X X X X Pulseoximetry X 12-Lead ECG³ X X X X X cECG X X X C-SSRS⁴ X X X SSS⁵ X X XMOAA/S⁶ X X X Plasma PK Samples⁷ X X Confined to Unit X X X X AdministerStudy Drug X Taste Assessment X Adverse Events X X X X X X ConcomitantMeds X X X X X X Study Completion X ¹Screening and Safety LaboratoryTests Food Cohorts: Visit 1 (Admission for Food cohort), V7 72 hpost-dose; V8 ²Vital Signs Food Cohort: V1 (Admission for Food cohort),V5 pre-dose and post-dose 15, 30, 60, 90, and 120 minutes, and 2.5, 3,3.5, 4, 4.5, 5, 5.5, 6, 7, 8, 10, 12, 14, 16, 22, and 24 hours afterdosing; V6 - 28, 32, 36, and 48 hours after dosing, V7 - 60 and 72 hoursafter dosing; V8. ³12-Lead ECG Food Cohort: V1 (Admission for Foodcohort), V5 pre-dose and post-dose 1, 2, 4, 8, 12, 24; V6 36, 48; V7 72hours; V8. ⁴C-SSRS Food Cohort: V1 Admission for Food; V7 post-dose, andV8. ⁵SSS Food Cohort: V5 - pre-dose and post-dose 1, 2, 3, 4, 5, 6, 7,8, 10, 12, 14, 16, 22, and 24; V6 - post-dose 28, 32, 36, 40 and 48hours; V4 - post-dose 60 and 72 hours. ⁶MOAA/S Food Cohort: V5 -pre-dose and post-dose 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 14, 16, 22, and24; V6 - post-dose 28, 32, 36, 40 and 48 hours; V7 - post-dose 60 and 72hours. ⁷See Appendix 2

TABLE 8 Schedule of Events EEG Cohort Visit V1 V2 V3 V4 V5 V6 V7 V8 V9Screen EEG EEG EEG EEG EEG EEG Follow Up End Study Visit Window D −28V2 + 24 h V2 + 48 h V2 + 7 d V5 + 24 h V5 + 48 h V2 + 14 d V2 + 21 d toD −1 0-+24 h to +48 h to +72 h 0 to +24 h to +48 h to +72 h (±1 d) (±1d) Informed Consent X Inclusion/Exclusion X Demographics X MedicalHistory X Physical Examination X X Body Weight/Height X CBC/SerumChemistry¹ X X X X X X Urinalysis X X X X X X Drug/Alcohol Screen X X XHepatitis & HIV Screen X Genetic Sample X Vital Signs² X X X X X X X XPulse oximetry X X 12-Lead ECG³ X X X X X X X X cECG X X X X X X C-SSRS⁴X X X X X SSS⁵ X X X X X X MOAA/S⁶ X X X X X X Bond-Lader Mood Scale⁷ XX X X X X X DEQ5⁸ X X X X X X Psychomotor Testing⁹ X X X X X X X EEG¹⁰ XX X X Eye Tracking¹¹ X X Plasma PK Samples¹² X X X X Confined to Unit XX X X X X Administer Study Drug X X Taste Assessment X Adverse Events XX X X X X X X X Concomitant Meds X X X X X X X X X Study Completion X¹Screening and Safety Laboratory Tests EEG Cohorts: V1 (Screening andDay −1 [Admission]); V2 pre-dose; V4 72 h post-dose; V5 (crossover)pre-dose; V7 72 h post-dose; V8 ²Vital Signs EEG Cohorts: V1 (Screeeningand Day −1 [Admission]), V2 pre-dose and post-dose 1, 2, 3, 4, 6, 8, 12,14, 16, 22 and 24 hours after dosing; V4-60 and 72 hours after dosing;V5 (crossover) - pre-dose and post-dose 1, 2, 3, 4, 5, 6, 7, 8, 10, 12,14, 16, 22, and 24 hours after dosing; V6 - 28, 32, 36, and 48 hoursafter dosing, V7 - 60 and 72 hours after dosing; V8. ³12-Lead ECG EEGCohort: V1 (Screening and Day −1 [Admission]; V2 - pre-dose; post-dose4, 8, 24; V5 48 and Visit 7 72 hours after dosing. ⁴C-SSRS EEG Cohorts:V1 (Day −1 [Admission]); V4 post-dose 72 h, V5 (crossover) pre-dose, V7post-dose 72 h, and V8. ⁵SSS EEG Cohorts: V2 - pre-dose and post-dose 2,4, 6, 8, 10, 12, 14, 16, 22, and 24 hours; V3 - post-dose 36 and 48hours; V4 - post-dose 60 and 72 hours; V5 (crossover) - pre-dose andpost-dose dose 2, 4, 6, 8, 10, 12, 14, 16, 22, and 24 hours; V6 -post-dose 36 and 48 hours; V7 - post-dose 60 and 72 hours. ⁶MOAA/S EEGCohorts: V2 - pre-dose and post-dose 2, 4, 6, 8, 10, 12, 14, 16, 22, and24 hours; V3 - post-dose 36 and 48 hours; V4 - post-dose 60 and 72hours. V5 (crossover) - pre-dose and post-dose dose 2, 4, 6, 8, 10, 12,14, 16, 22, and 24 hours; V6 - post-dose 36 and 48 hours; V7 - post-dose60 and 72 hours. ⁷BL-VAS EEG Cohorts: V2 - pre-dose and post-dose 2, 12and 24 hours; V3 - post-dose 36 and 48 hours; V4 - post-dose 72 hours;V5 (crossover) - pre-dose and post-dose dose 2, 12 and 24 hours afterdosing; V6 - post-dose 36 and 48 hours; V7 - post-dose 72 hours; V8.⁸DEQ5 EEG Cohorts: V2 - pre-dose and post-dose 2, 12 and 24 hours; V3 -post-dose 36 and 48 hours; V4 - post-dose 72 hours; V5 (crossover) -pre-dose and post-dose dose 2, 12 and 24 hours; V6 - post-dose 36 and 48hours; V7 - post-dose 72 hours. ⁹Psychomotor testing EEG Cohorts: V2 -pre-dose and post-dose 3, 8 and 24 hours. V3 post-dose 48 hours; V4 -post-dose 72 hours; V5 (crossover) - pre-dose and post-dose 3, 8 and 24hours; V6 post-dose 48 hours; V7 - post-dose 72 hours. Subjects willcomplete a practice session during Screening and on Day −1 (Admission).¹⁰EEG relaxation epochs EEG Cohorts: V2 and V5: −20 to −15 minutesbefore dosing post-dose 60 (1 hour) to 65 minutes; 120 (2 hours) to 125minutes; 420 (7 hours) to 425 minutes; 1,380 to 1,385 minutes (23 hours)after dosing. A relaxation epoch may be added or the timing of therelaxation epochs adjusted based on T_(max) or other findings observedduring the SAD part of the study. ¹¹Eye Tracking EEG Cohorts: V2 andV5 - pre-dose and post-dose 2.5, 7.5, 9.5 and 23.5 hours. ¹²See Appendix2.

TABLE 9 Schedule of Events Essential Tremor Cohort Visit V1 V2 V3 V4 V5Visit Window −28 d −24 h 0 h +24 h V2 + 7 d V2 + 14 d to −24 h to 0 h to+24 h to +48 h (±1 d) (±1 d) Visit Days Screen Admit D 1 D 2 Follow UpEnd Study Informed Consent X Inclusion/Exclusion X Demographics XMedical History X Physical Examination X X Body Weight/Height XCBC/Serum Chemistry¹ X X X Urinalysis X X X Drug/Alcohol Screen X XHepatitis & HIV Screen X Genetic Sample X Vital Signs² X X X X X Pulseoximetry² X X 12-Lead ECG³ X X X X X C-SSRS⁴ X X X X SSS⁵ X X X MOAA/S⁶X X X Bond-Lader Mood Scale⁷ X DEQ5⁸ X Kinesia X X TETRAS Performance XX Subscale⁹ Plasma PK Samples¹⁰ X X Confined to Unit X X AdministerStudy Drug X Adverse Events X X X X X X Concomitant Meds X X X X X XStudy Completion X ¹Screening and Safety Laboratory Tests EssentialTremor Cohort: V1 (Screening and Day −1 [Admission]); V2 pre-dose; V4.²Vital Signs Essential Tremor Cohort: V1 (Screening and Day −1[Admission]); V2 pre-dose and post-dose 1, 2, 3, 4, 6, 8, 12, 14, 16 and24 hours; V3 48 hours after dosing; V4. Continuous pulse oximetrybeginning 30 minutes pre-dose and through 24 h post-dose. ³12-Lead ECG:V1 (Screening and Day −1 [Admission]); V2 pre-dose; post-dose 4, 8, 24;V3 48; V4. ⁴C-SSRS Essential Tremor Cohort: V1 (Day −1 [Admission]); V2post-dose 24 h; V3 post-dose 48 h; V4. ⁵SSS Essential Tremor Cohort: V2pre-dose and post-dose 2, 4, 6, 8, 10, 12, 14, 16 and 24 hours; V3 48hours; V4.. ⁶MOAA/S Essential Tremor Cohort: V2 pre-dose and post-dose2, 4, 6, 8, 10, 12, 14, 16 and 24 hours; V3 48 hours; V4. ⁷BL-VASEssential Tremor Cohort: V2 pre-dose and post-dose 2, 12 and 24 hours.⁸DEQ5 Essential Tremor Cohort: V2 pre-dose and post-dose 2, 12 and 24hours. ⁹Kinesia and TETRAS Testing Essential Tremor Cohort: V1(Admission/Eligibility); V2 - pre-dose (3 assessments separated by atleast 30 min) and post-dose 1, 2, 4, 6, 8, 12 and 24 hours after dosing.¹⁰PK sampling times: See Appendix 2.

Five cohorts in this single ascending dose study have been dosed andthis study is ongoing. The following adverse events have been reportedto date and deemed by the investigator as possibly or probably relatedto the study drug; mild drowsiness, mild confusion, somnolence,headache, orthostatic heart rate increase, aloofness, anxiety, sorethroat and mild abdominal discomfort.

Expected risks are those identified during the toxicology and safetypharmacology studies for Compound 9 and clinical study Example 2. Themost common drug-related effect seen across species, studies and doseswas dose-related sedation. This will be monitored in the clinical studyusing two scales, one designed to monitor “sleepiness” (StanfordSleepiness Scale) and one to monitor deeper sedation (ModifiedObserver's Assessment of Alertness/Sedation).

Other effects were noted in toxicology studies but were determined to benon-adverse, reversible and possibly related to Compound 9administration. In both male and female rats, a slight prolongation ofAPTT without microscopic correlates, a slight increase in urine pHwithout microscopic correlates, and slight increases (<2-fold) inAST/ALT in high dose male and female rats with microscopic correlates(increased incidence of minimal hepatocellular vacuolation) were found.In dogs, transient decreases in core body temperature, transientincreases in heart rate, and minimal renal tubular vacuolation (awell-documented vehicle effect (Stella and He, 2008)) were observed.

A Safety Review Committee will be employed to review available data fromeach cohort and to determine the dose selection for the subsequentcohort, not to exceed the maximum proposed dose for each cohort. Theprotocol also includes clear stopping rules with regard to sedation andother medical events of interest, as well as seriousness and severity ofadverse events.

The ability to monitor for most of these effects and the carefulconsideration of safety data before increasing the dose for the nextcohort, and the pre-specified escalation and stopping rules mitigate therisk of these effects.

As seen in FIG. 8 , MOAA/S≤2 was one of the stopping criteria for doseescalation. 2 subjects in the 66 mg dose of SAD (stopping criteria met);2 subjects in the 55 mg dose of SAD (stopping criteria not met). 2subjects had a MOAA/S score of ≤2, which upon repeat one subject had avalue of >2.

MOAA/S Scale: 0, No response after painful trapezius squeeze; 1,Responds only after painful trapezius squeeze; 2, Responds only aftermild prodding or shaking; 3, Responds only after name is called loudlyand/or repeatedly; 4, Lethargic response to name spoken in normal tone;5, Responds readily to name spoken in normal tone.

As shown in FIG. 9 , Scores of 1 or 2 (deep sedation) only observed fortwo subjects in 35 mg group; all occurred at 1 hour post-dose. By 4hours post-dose, mean MOAA/S approached baseline values.

Example 3. Phase I, Double-Blind, Placebo-Controlled, Multiple AscendingDose Study to Determine Safety, Tolerability, Pharmacokinetics andPharmacodynamics of Compound 9 Oral Solution in Healthy VolunteersPurpose

-   -   To determine the safety and tolerability of multiple doses of        Compound 9 Oral Solution in healthy volunteers aged 18-55 years        as assessed by spontaneously reported adverse events, physical        examination, vital sign measurements, laboratory testing,        12-lead ECGs, the Stanford Sleepiness Scale (SSS), Modified        Observer's Assessment of Alertness/Sedation Scale (MOAA/S), and        the Columbia-Suicide Severity Rating Scale (C-SSRS).    -   To determine the pharmacokinetic (PK) profile of multiple doses        of Compound 9 Oral Solution as assessed by the calculation of        standard PK parameters;    -   To investigate concentrations of Compound 9 metabolites in        plasma and urine after multiple oral dosing;    -   To investigate the pharmacodynamic effects of multiple doses of        Compound 9 Oral Solution as assessed by psychomotor testing        (Cogstate Early Phase Battery consisting of Detection Task,        Identification Task, One Card Learning Task, and Groton Maze        Learning Test), mood, anxiety and depression (the Bond-Lader VAS        and Hospital Anxiety and Depression Scale), drug likeability        (the Drug Effects Questionnaire—5), and electroencephalography        (EEG) with eye tracking;    -   To investigate whether Compound 9 Oral Solution induces the        metabolism of drugs metabolized via the CYP3A4 and CYP2B6        pathways as assessed by dosing simvastatin and bupropion before        and after exposure to Compound 9 in the Drug-Drug-Interaction        (DDI) Cohort.

Materials

Compound 9 Oral Solution is available as 1 mg/mL and 6 mg/mL stockaqueous solutions of Compound 9 Drug Substance containing 40% HPBCD(Kleptose®) and 0.0025% sucralose which is further diluted with SterileWater for Injection to achieve the selected dosages. The 1 mg/mL and 6mg/mL stock Compound 9 Oral Solutions will be compounded from Compound 9Drug Substance Powder in the Bottle and Excipient (s) in the Bottle(manufactured under cGMP conditions at Pharmatek) and further admixed atthe clinical site in preparation for dosing. Placebo will be matched tostudy drug at each dose cohort. Detailed instructions for study drugpreparation will be provided in the Pharmacy Manual. The PAREXELclinical Phase I unit will be responsible for procuring the CYPinduction drugs (bupropion and simvastatin). For the bupropion dosing,Wellbutrin IR® is preferred but a generic may be substituted withpermission from the Sponsor. The generic equivalent of Zocor® isacceptable for simvastatin.

The composition and pharmaceutical quality of the investigationalproduct will be maintained according to the current Good ManufacturingPractice (GMP) and Good Clinical Practice (GCP) guidelines and availablefor review in the study medication documentation. Compound 9 will beprovided to the Phase 1 unit as powder in the bottle and excipient (s)in the bottle units and compounded in the pharmacy at a volume of 125 mLof either a 1 mg/mL or 6 mg/mL stock solution and then further dilutedto approximately 40 mL at the identified doses. Study drug labels withall required information and conforming to all applicable CFR andGMP/GCP guidelines will be prepared by the Phase I unit.

The study medication must be carefully stored at the temperaturespecified in the pharmacy manual (e.g., clinical dosing solutions storedat approximately 2-8° C. or room temperature for up to 24 hours afterpreparation), safely and separately from other drugs.

Treatment Protocol

This study comprises a double blind, placebo-controlled multipleascending dose (MAD) study followed by an open-label drug-druginteraction study (DDI) without placebo in healthy, adult volunteers.Four cohorts of 12 subjects each will be recruited for a total of 48subjects. Subjects in Cohorts 1, 2, and 3 will participate in themultiple-ascending-dose (MAD) part of the study, and subjects in Cohort4 will participate in the drug-drug-interaction (DDI) part of the study.

The objective of the MAD part of the study is to determine the safety,tolerability, pharmacokinetics (PK), and pharmacodynamic (PD) profile ofseven days of dosing with Compound 9 Oral Solution (henceforth referredto as Compound 9).

Safety will be assessed utilizing physical examination, vital signmeasurements, safety laboratory testing, 12-lead ECGs, sedation scores(the Stanford Sleepiness Scale (SSS) and Modified Observer's Assessmentof Alertness/Sedation Scale (MOAA/S), and the Columbia-Suicide SeverityRating Scale (C-SSRS). Tolerability will be assessed by spontaneouslyreported adverse events.

The pharmacodynamic (PD) effects of multiple days of dosing withCompound 9 will be assessed in Cohorts 1-3. Pharmacodynamic effects onthe central nervous system (CNS) will be assessed using psychomotortesting (Cogstate Early Phase Battery or similar consisting of DetectionTask, Identification Task, One Card Learning Task, and Groton MazeLearning Test), mood, anxiety and depression (the Bond-Lader VAS forself-reported mood assessment and the Hospital Depression and AnxietyScale [HADS]), a drug likeability questionnaire (Drug EffectsQuestionnaire [DEQ-5]), and electroencephalography (EEG) with eyetracking. Sleep quality will be assessed via a subject-ratedquestionnaire in Cohort 3 Part 2 (nighttime dosing).

The planned total daily dose for each MAD cohort is based on informationobtained during the ongoing single, ascending dose (SAD) study (Example2). Information such as the half-life of a single dose of Compound 9will be reviewed to determine whether to dose once-daily (QD) ortwice-daily (BID) dosing. The planned total daily dose for each cohortin Example 3 based on the SAD study is provided below:

-   -   Cohort 1: Dose from the Phase I SAD study that achieved an AUC        of approximately 400 ng*h/mL    -   Cohort 2: Approximately 2 to 4 times the dose tested in Cohort 1    -   Cohort 3: Approximately the MTD from the SAD study

If dosing QD during the MAD part of the study, the total daily dose ofCompound 9 or placebo for each cohort will be administered in themorning for 7 days.

If dosing is twice daily (BID), the total daily dose will be equallydivided and 50% administered in the morning and 50% in the evening forsix days; 50% of the total daily dose will be administered in themorning only on Day 7 to allow for a full PK profile. Morning dosingwill be between the hours of approximately 08:00 h and 09:00 h andevening dosing will be between the hours of approximately 19:00 h and20:00 h. Compound 9 will be administered in the morning to fastedsubjects after a minimum of an 8 hour fast with a standard dietbeginning approximately 4 hours after dosing.

Fasting is not required prior to any evening dosing. Note that the timeof dosing in each cohort may be staggered/adjusted depending on timingof other assessments, e.g., EEG. The doses for each regimen will beselected based on information from the single ascending dose (SAD) Phase1 study using the following criteria:

-   -   Cohort 1: the Compound 9 total daily dose will approximate the        SAD dose that resulted in a median AUC of approximately 400        ng*h/mL;    -   Cohort 2: the Compound 9 total daily dose will approximate a        two-to-four-fold increase from the Cohort 1 MAD dose based on        clinical observations from Cohort 1;    -   Cohort 3: the Compound 9 total daily dose will approximate the        SAD study MTD. If once daily dosing is employed, Part 1 of        Cohort 3 will be administered the total daily dose of Compound        9/placebo between approximately 08:00 h and 09.00 h each morning        and Part 2 of Cohort 3 will be administered the total daily dose        of Compound 9/placebo between approximately 19:00 h and 20:00 h.        If twice daily dosing is employed, Cohort 3 may have only one        part.    -   If Cohort 3 Part 2 is not utilized for evening dosing, the SRC        may use the second part of Cohort 3 for exploratory doses or        dosing regimens as long as the total daily dose does not exceed        the total daily dose used in the MAD part of the study.

Of the 12 subjects in the MAD cohorts, nine will be randomized toCompound 9 and three will be randomized to placebo. If dosing is QD forthis study, subjects participating in Cohort 3 will be dosed in themorning for seven days (Part 1), then after a suitable washout period ofat least seven days return for a second period of seven days' dosing inthe evening (Cohort 3 Part 2). If Cohort 3 Part 2 subjects return forevening dosing, they will receive the same study drug (active orplacebo) for the evening dosing as they did for the morning dosing. IfBID dosing is employed, Cohort 3 will not return for a second period ofdosing, unless the Safety Review Committee decides to utilize Cohort 3Part 2 to explore a lower dose than that administered in the first partof Cohort 3, or to evaluate a different dosing regimen. The total dailydose will not exceed those evaluated during the earlier parts of the MADpart of the study. Concentrations of Compound 9 in plasma and urine willbe assessed after multiple days of oral dosing. Pharmacokinetics will beassessed based on parameters derived from frequent sampling forbioanalysis of Compound 9 concentrations. Metabolite concentrations ofCompound 9 in plasma and in urine will also be investigated.

CYP Drug-Drug Interaction Dosing Regimen

The DDI part of the study (Cohort 4) will investigate whether multipledosing with Compound 9 induces the metabolism of either the CYP3A4 orCYP2B6 enzyme. All 12 subjects in the DDI part of the study will receiveCompound 9 in an open-label fashion with the total daily dose ofCompound 9 approximating the maximum well-tolerated single doseadministered in the MAD part of the study.

As with the MAD part of the study, it may be required to administerCompound 9 using a BID regimen. The DDI cohort dosing schedule isprovided below. Compound 9 dosing is with subjects in fasted stateunless it is decided to administer Compound 9 BID in which case only themorning dose would be administered with subjects in a fasted state;subjects may have a standard breakfast prior to dosing with bupropion orsimvastatin. The dosing regimen for the DDI part of the study ispresented below:

-   -   Day 1: Bupropion 100 mg (Wellbutrin IR® or generic equivalent)    -   Day 2: Simvastatin 20 mg (Zocor® or generic equivalent)    -   Days 3-9: Compound 9 at approximately the MAD MTD    -   Day 10: Simvastatin 20 mg (Zocor® or generic equivalent)    -   Day 11: Bupropion 100 mg (Wellbutrin IR® or generic equivalent)

Plasma samples will be obtained to fully characterize the concentrationsof simvastatin, bupropion, and Compound 9 and comparisons made forsimvastatin and bupropion concentrations before and after Compound 9administration.

Dose Escalation and Stopping Rules

The SRC may stop dose escalation and may permit ongoing dosing at thesame or lower total daily doses if any of the following occur:

-   -   Serious Adverse Event: If any subject in a cohort has a serious        adverse event (SAE) that the SRC determines is related to        Compound 9, the SRC may stop the MAD phase of the study or may        permit ongoing dosing at lower doses of Compound 9 than that at        which the event occurred, depending on the nature of the event.    -   Severe Adverse Event: If three or more active treatment subjects        in a cohort have a severe adverse event that the safety        committee determines is related to Compound 9, the safety        committee may stop the MAD phase of the study or may permit        ongoing dosing at the same or lower doses of Compound 9,        depending on the nature of the event and the dose(s) at which        the events occurred.    -   MOAA/S Score: If at least one Compound 9-exposed subject within        a cohort has a MOAA/S score of two or less (≤2) at any time        point during normal waking hours (≥08:00 h to ≤22:00 h) and this        score is confirmed i.e., repeat assessment is the same or lower,        or if two or more (≥2) Compound 9-exposed subjects have a        confirmed MOAA/S score of three or less (≤3) at any time point        during normal waking hours (≥08:00 h to ≤22:00 h), dose        escalation to the next planned dose will not occur.

Additional dosing may be permitted by dosing Compound 9 at a lower doseor by repeating the dose at which these events occurred depending on theextent and duration of the sedation and the dose(s) at which thesedation occurred. The Safety Review Committee will consider MOAA/Sscores as qualifying for stopping criteria only when the confirmationscore is equal to or lower than the first assessment and when there iscongruence with the SSS score at the same time point.

-   -   If any of the following findings occur in at least two (2)        subjects exposed to Compound 9 Oral Solution within a cohort and        the findings are confirmed (if applicable), the SRC may not        allow dose-escalation if at least two subjects report the same        finding. However, if each subject reported a different finding,        the SRC could allow dose escalation at lower doses than planned.        In all circumstances the SRC may allow dose repetition or dose        reduction:        -   An increase from pre-dose in supine systolic blood pressure            of 60 mmHg sustained for at least five minutes, or a            decrease from pre-dose in supine systolic blood pressure of            30 mmHg sustained for at least five minutes, or supine            systolic blood pressure of ≤70 mmHg or ≥200 mmHg sustained            for at least five minutes;        -   An increase from pre-dose in supine diastolic blood pressure            of 40 mmHg sustained for at least five minutes, or a            decrease from pre-dose in supine diastolic blood pressure of            30 mmHg sustained for at least five minutes, or supine            diastolic blood pressure of ≤40 mmHg or ≥110 mmHg sustained            for at least five minutes;        -   An increase from pre-dose in supine heart rate of 50 bpm            sustained for at least five minutes, or a decrease from            pre-dose in supine heart rate of 30 bpm sustained for at            least five minutes, or supine heart rate of ≤45 bpm or ≥170            bpm sustained for at least five minutes;        -   QTc prolongation defined as QTcF increasing >60 msec and            persisting for at least 10 minutes or QTcF >500 msec and            persisting for at least 30 minutes;        -   A sustained increase in alanine aminotransferase (ALT) or            aspartate aminotransferase (AST) to >3× upper limit of            normal (ULN), which must be confirmed elevated >3×ULN within            48 hours (Guideline of Liver Safety Assessment Best            Practices Workshop 2014 [Avigan et al., 2014]);        -   Total bilirubin increase to >2×ULN confirmed on repeat            testing in fed condition within 48 hours;        -   ALT or AST >2×ULN concurrent with total bilirubin >1.5×ULN            confirmed on repeat testing within 48 hours;        -   Serum creatinine >1.5×ULN confirmed on repeat testing within            48 hours;        -   Leukocyte count <2.5×109/L confirmed on repeat testing            within 48 hours;        -   Neutrophil count <1.0×109/L confirmed on repeat testing            within 48 hours;        -   Platelet count <100×109/L confirmed on repeat testing within            48 hours.        -   AUC and Cmax: based on the plasma concentration information            from previous cohorts, the SRC will consider adjusting the            dose (dose reduction, dose repetition, or reduced dose            escalation) for the next cohort if the Cmax of >50% of the            next cohort is expected to exceed 400 ng/mL (the estimated            human Cmax based on the lowest NOAEL Day 14 Cmax in female            rats). In addition, the SRC will not allow escalation to            doses beyond those predicted to result in a median AUC above            the lowest NOAEL exposure in toxicology studies (male rat            14-day toxicology, AUC 5,050 ng·h/mL).

Statistical Considerations

The Safety Population is defined as all subjects who are administeredstudy drug. The Pharmacokinetic (PK) Population is defined as allsubjects who are administered Compound 9 and have at least onebioanalysis result for the plasma concentration of Compound 9.

No formal sample size calculations have been undertaken for this safetyand tolerability study. The number of subjects in each cohort and ateach dose level is thought to be sufficient to assess preliminary safetyand tolerability following multiple doses of Compound 9. No efficacyparameters are being collected or analyzed for this Phase I study.

For all safety analyses of the MAD portion of the study, the placebodose group will be pooled across cohorts. AEs will be coded usingMedDRA™ with the version used specified in the clinical study report.The overall incidence of AEs will be displayed by System Organ Class(SOC), preferred term, dose group, and cohort. Incidence of AEs willalso be presented by maximum severity and relationship to study drug.Data from vital signs, clinical laboratory measures, ECG, and C-SSRSwill be summarized using descriptive statistics by dose group andcohort, where applicable. Continuous endpoints will be summarized withn, mean, standard deviation, median, minimum and maximum. In addition,change from baseline values will be calculated at each time point andwill be summarized using the same summary statistics. Out-of-rangesafety endpoints may be categorized as low or high, where applicable.For all categorical endpoints, summaries will include counts andpercentages.

PK parameters will be summarized using appropriate descriptivestatistics. Time to reach maximum concentration (Tmax) will besummarized using n, mean, standard deviation, median, minimum, andmaximum. All other PK parameters will be summarized using n, geometricmean, coefficient of variation, median, minimum, and maximum.

Dose proportionality will be analyzed using an ANCOVA model using thelogarithm of PK parameter (AUC and Cmax) as the dependent variable andthe logarithm of the dose as the independent variable. Point estimatesand the corresponding CIs will be estimated for both AUC and Cmax. Toevaluate the effect of administration of Compound 9 on the plasma PKprofile of the test drug simvastatin and the test drug bupropion, PKparameters for AUC and Cmax for simvastatin and bupropion will benatural log-transformed and evaluated using a linear mixed effects modelwith fixed effects terms for treatment. An unstructured covariancematrix will be used to allow for unequal treatment variances and tomodel the correlation between the treatment measurements within eachsubject via the REPEATED statement in SAS PEOC MIXED. Kenward andRoger's method will be used to calculate the denominator degrees offreedom for the fixed effects (DDFM=KR).

A ninety percent (90%) confidence interval (CI) will be constructed forthe difference in least squares means on the log scale for each of AUCand Cmax.

Exponentiating the log-scale 90% CI will provide a 90% CI for thegeometric mean ratios (simvastatin+Compound 9/simvastatin alone orbupropion+Compound 9/bupropion alone).

The secondary endpoints of SSS, MOAA/S, BL-VAS, HADS and DEQ-5 valueswill be summarized using the same descriptive statistics described abovefor the safety variables. The pharmacodynamics analysis of EEG endpointsand their relationship to psychomotor testing and eye tracking measureswill be described in a separate analysis plan. In addition, PK/PDexploratory analyses will be performed utilizing sedation, mood,anxiety, depression, EEG and psychomotor data. Further details of theabove analyses will be provided in the statistical analysis plan.

Placebo will be matched to study drug for each multiple ascending dose(MAD) cohort. The drug-drug interaction (DDI) part of the study will beconducted in an open-label manner with Compound 9, bupropion andsimvastatin.

Procedures/Measurements

Cohorts 1 and 2 of the MAD part of the study will consist of up to 14visits over a period of up to 28 days prior to dosing, approximately 11days confined to unit (admission, 7 days of dosing with Compound 9 andup to 3 days of follow up) and approximately 14 days after the last doseof Compound 9.

Cohort 3 (Parts 1 and 2 assuming QD dosing) will consist of up to 25visits over a period of up to 28 days prior to dosing, approximately 22days confined to unit (two 11-day periods of [admission 7 days of dosingwith Compound 9 and up to 3 days of follow up with each Compound 9dosing period] separated by approximately 7 days) and approximately 14days after the last dose of Compound 9. If MAD dosing is determined tobe BID, Cohort 3 will either not take place or will have a dosingregimen determined by the SRC with total daily dose not exceeding themaximum total daily dose tested during the previous cohorts.

The DDI cohort will consist of up to 16 visits over a period of up to 28days prior to CYP-induction drug dosing, approximately 13 days confinedto the unit (admission, 2 days of CYP-induction drug dosing, 7 days ofdosing with Compound 9, a 3-day in-house follow up after last dose ofCompound 9 (which includes 2 days of CYP-induction drug dosing) and 14days after the last dose of Compound 9. During each phase of the study,subjects will be admitted to the unit approximately 24 hours prior tothe first dose of study drug (either Compound 9 [Cohorts 1, 2 and 3] orCYP-induction drug [Cohort 4]). During the MAD and DDI parts of thestudy, subjects will be confined to the unit for approximately 72 hoursafter the last dose of Compound 9 (or placebo in the MAD part of thestudy); subjects may be released sooner if it is predicted that plasmaconcentrations of Compound 9 will be below the level of quantificationearlier than 72 hours after dosing. No subject may be discharged fromthe unit until the Investigator is satisfied that it is safe for thesubject to be discharged from the unit.

Physical examinations, vital signs, laboratory assessments andobservations by experienced Phase I personnel will be undertakenthroughout the study based on the Schedules of Events. The StanfordSleepiness Scale (SSS) and Modified Observer's Assessment ofAlertness/Sedation Scale (MOAA/S) will be used to assess sedationeffects. The Bond-Lader VAS and the Hospital Anxiety and DepressionScale (HADS) will assess different aspects of self-reported mood,anxiety and depression; the Drug Effects Questionnaire (DEQ-5) willassess whether the subject “liked” the drug and/or felt “high”.Psychomotor testing will be undertaken in the MAD cohorts to assesscognitive function in a variety of domains such as attention, workingmemory, episodic secondary memory, executive function, and motor skills.Sleep will be assessed in Cohort 3 Part 2 if dosing is QD.

An EEG with at least 24 channels set for continuous recording will beapplied approximately 1 hour prior to dosing and kept in place forapproximately 9 hours after Compound 9/placebo dosing for Cohorts 1, 2and 3 Part 1 on Days 1 and 7.

EEG relaxation epochs and eye tracking will be completed atapproximately 30 minutes pre-dose and at approximately 2 and 8 hourspost-dose.

See the Schedule of Events tables for each cohort for the full list ofstudy assessments and timings.

Subjects

Approximately 48 healthy subjects will be recruited into the study.

Inclusion Criteria

-   -   1. Signed informed consent before any study-specific procedures        are performed;    -   2. Healthy ambulatory male and female subjects ≥18 to ≤55 years        of age at the Screening visit, with no history or evidence of        clinically relevant medical disorders as determined by the        Investigator in consultation with the Sponsor.    -   3. Bodyweight ≥50 kg and body mass index (BMI) ≥18.0 and ≤32.0        kg/m2 at the screening visit.    -   4. Physical and neurological examination, clinical laboratory        values, vital signs (normal ranges per the Investigator), and        electrocardiograms (ECGs) are clinically acceptable to the        Investigator.    -   5. Male subjects must agree to practice an acceptable method of        highly effective birth control from the Screening visit, while        on study and for 13 weeks after receiving the last dose of study        drug. Highly effective methods of birth control include sexual        abstinence; vasectomy; or a condom with spermicide (men) in        combination with a highly effective female partner's method,        e.g. hormonal birth control, or intrauterine device. Female        subjects must be non-childbearing capacity, e.g. postmenopausal        (at least 12 months since last menstruation) or surgically        sterile (tubal ligation, bilateral oophorectomy, hysterectomy).    -   6. Males must be willing to abstain from sperm donation from the        Screening visit, while on study and through 13 weeks after        receiving the last dose of study drug.

Key Exclusion Criteria

-   -   1. Clinically significant abnormal values for hematology,        clinical chemistry or urinalysis at the screening and admission        visits. Abnormalities considered to be non-clinically        significant by the Investigator are acceptable.    -   2. Subject with history of suicidal behavior within two years or        who has answered YES to questions 3, 4 or 5 on the C-SSRS at the        screening or admission visits, or is currently at risk of        suicide in the opinion of the Investigator.    -   3. Clinically significant abnormal physical examination OR        12-lead electrocardiogram (ECG) at the screening or admission        visits. NOTE: QTcF interval of ≥450 msec in males or ≥470 msec        in females, will be the basis for exclusion from the study. ECG        may be repeated for confirmatory purposes if initial values        obtained exceed the limits specified.    -   4. Significant history and/or presence of hepatic, renal,        cardiovascular, pulmonary, gastrointestinal, hematological,        immunologic, ophthalmologic, metabolic or oncological disease.    -   5. History or presence of psychiatric or neurologic disease or        condition (including but not limited to epilepsy, closed head        trauma with clinically significant sequelae, partial onset        seizures, eating disorders, etc.).    -   6. Recent history (within previous six months prior to        screening) of alcohol or drug abuse (as judged by the        Investigator), or has consumed >2 alcohol drinks/day during the        last three months prior to screening (one glass is approximately        equivalent to: beer [284 mL], wine [125 mL/4 ounces], or        distilled spirits [25 mL/1 ounce]). Subjects that consume three        glasses of alcoholic beverages per day but less than 14 glasses        per week may be enrolled at the discretion of the Investigator.        Positive screens for alcohol or controlled substances at the        screening or admission visits will disqualify a subject from        study participation.    -   7. Any subject who currently uses or has regularly used tobacco        or tobacco containing products (cigarettes, pipes, etc.) for at        least 30 days prior to screening OR positive urine cotinine        screen (>400 ng/mL) at the screening or admission visits.    -   8. Any subject with a history, presence and/or current evidence        of serologic positive results for hepatitis B surface antigen,        hepatitis C antibodies, or HIV antibodies 1 or 2.    -   9. Donation of blood or acute loss of blood within 60 days prior        to the Screening visit.    -   10. Any subject who has received treatment with an        investigational drug during the 30 days, or 5 half-lives,        whichever is longer, prior to the Screening visit. Exposure to        an investigational medical device within 30 days of the        Screening visit.    -   11. Use of any prescription or over-the-counter medication,        herbal medication, vitamins, or mineral supplements within 14        days prior to first administration of the study drug.    -   12. Use of agents known to affect drug metabolism: use of any        known CYP3A4 or CYP2B6 inhibitors and/or inducers within 14 days        prior to first administration of study drug, or 5 half-lives        (whichever is longer) or consumed grapefruit juice, grapefruit,        Seville oranges or St John's Wort or products containing these        within 30 days prior to first administration of study drug.    -   13. Any subject who consumes excessive amounts of caffeine,        defined as greater than 6 servings (1 serving is approximately        equivalent to 120 mg of caffeine) of coffee, tea, cola, or other        caffeinated beverages per day within 30 days prior to the        Screening visit.    -   14. Any subject with previous exposure to Compound 9 or who is        known to be allergic to Compound 9 or any of its excipients,        including its major excipient HPBCD, or for Cohort 4 has known        allergy to bupropion or simvastatin. Previous exposure to        simvastatin and/or bupropion is allowed.    -   15. Investigative site personnel or their immediate families        (spouse, parent, child or sibling whether biological or legally        adopted).    -   16. Any subject unwilling or unable to comply with study        procedures.

Pharmacokinetic Assessments

Pharmacokinetic blood samples will be taken and processed for analysisfor concentrations of Compound 9 at the time points described. Selectedsamples may also be analyzed for concentrations of Compound 9metabolites; urine samples will also be tested for concentrations ofCompound 9. Samples from subjects participating in Cohort 4 will also betested for concentrations of simvastatin, simvastatin acid, bupropionand hydroxyl-bupropion.

Blood Sample Collection

Plasma samples for PK analysis will be collected according to thesampling collection times specified for the MAD and the DDI cohorts. Thetime of study drug administration is time zero and all post-dosingsampling times are relative to this time. The Investigator or designeewill arrange to have the plasma samples processed, stored andtransported as directed for bioanalysis.

Selected samples may also be analyzed for concentrations of metabolitesof Compound 9.

An additional PK sample may be collected at any time if clinicallyindicated and at the discretion of the Investigator (e.g. for unusual orsevere AEs).

Each sample will be marked with unique identifiers such as the studynumber, subject number, and the nominal sample time. The date and actualtime that the blood sample was taken

Urine Sample Collection

During the MAD phase only (Cohorts 1 and 2; Cohort 3 Part 1) on Days 1and 7 all voided urine will be collected and pooled over the followingtime periods: pre-dose; 0-4 hours; 4-8 hours; and 8-12 hours. A samplewill be obtained from each pooled sample and processed for analysis ofCompound 9 concentrations. Urine samples may also be analyzed forCompound 9 metabolite concentrations. The pre-dose urine sample is to becollected within approximately 60 minutes prior to dosing. The post-dosecollection periods are relative to dosing.

Storage and Shipment of Pharmacokinetic and Urine Samples

The plasma and urine samples should be kept frozen at approximately −70°C. to −80° C. until analyzed. They should be packed as directed to avoidbreakage during transit and with sufficient dry ice to prevent thawingfor at least 72 hours. A specimen-identification form must be completedand sent to the laboratory with each set of samples. The clinical sitewill arrange to have the plasma and urine samples transported asdirected for bioanalysis as detailed in the PK instructions.

Sample Analysis

Bioanalysis of plasma samples for the determination of Compound 9 willbe performed utilizing a validated LC-MS/MS method at AgiluxLaboratories, Worcester, MA; bioanalysis of plasma samples for thedetermination of simvastatin, simvastatin acid, bupropion, andhydroxylbupropion levels will be conducted at a qualified laboratory.The methodology for urine bioanalysis is in development and will beconducted at a later time using the stored samples.

Genomics Samples

Plasma samples will be taken from consenting participants in all cohortson Day −1 (Admission) (timing on Day 1 is flexible and will bedetermined by PAREXEL) and retained for possible future genomicsstudies. The genomics samples will be stored at PAREXEL until theSponsor identifies a suitable laboratory. Note that providing thissample is optional for subjects under a separate consent form.

Safety Parameters

The safety and tolerability of multiple doses of Compound 9 will beassessed via adverse event reporting, vital sign measurement, laboratorydata, ECG parameters, sedation scores and assessment of suicidalideation using the Columbia-Suicide Severity Rating Scale (C-SSRS).

During each phase of the study, subjects will be admitted to the unitapproximately 24 hours prior to the expected time of dosing withCompound 9/placebo or CYP-interaction drug. Subjects will be confined tothe unit for approximately 72 hours after completion of the Compound 97-day dosing period for all cohorts; subjects may be released sooner ifit is predicted that plasma concentrations of drug will be below thelevel of quantification earlier than 72 hours after Compound 9 dosing.No subjects may be discharged from the unit until the Investigator issatisfied that it is safe for the subject to be discharged from theunit.

Physical examinations, vital signs, laboratory assessments andobservations by experienced Phase I personnel will be undertakenthroughout the study based on the following sections and Schedules ofEvents. All study assessments may be performed by suitably trainedpersonnel, but the results must be reviewed and signed off by medicalpersonnel.

PK samples and safety and pharmacodynamic assessments are currentlyplanned to coincide with Tmax, but sample timing may be adjusteddepending on the PK data observed earlier in the clinical developmentprogram.

-   -   Compound 9 daytime dosing days are Days 1-7 for Cohorts 1, 2 and        3 and Days 3-9 for Cohort 4.    -   Compound 9 evening dosing days are Days 1-7 for Cohort 3 Part 2        (if applicable).    -   Compound 9 non-dosing days include: Day −1 (Admission) for all        cohorts; Days 8, 9 and 10 for Cohorts 1, 2 and 3; and Days 1, 2,        10, 11 for Cohort 4.    -   Compound 9 “frequent sampling days” are Days 1 and 7 in Cohorts        1, 2 and 3 and Days 3 and 9 for Cohort 4.

12-Lead Electrocardiogram (ECG)

The 12-lead ECG assessments will be performed after the subject has beensupine for at least approximately 5 minutes and the standard intervalsrecorded as well as any abnormalities. All time points are relative tothe time of dosing. If the ECG planned time point is between the hoursof approximately ≥22:00 h and ≤08:00 h each day or if the subject hasbeen discharged before the last time point, the assessment need not beconducted at that time point. Timing for this assessment may be adjusteddepending on Tmax timing observed in the Example 2 SAD study. Timing ispresented below. On daytime PK frequent sampling days (relative days 1and 7): if once daily dosing obtain predose and 2, 4, 8 and 12 hourspost dose, or if twice daily dosing obtain pre-dose and 2, 4, 8, 12hours post the morning dose, and 2 hours after the evening dose.

On daytime Compound 9/placebo dosing days (relative days 2-6): if oncedaily dosing obtain predose and 2 and 4 hours post-dose, or if twicedaily dosing obtain pre-dose and 2 and 4 hours post the morning dose,and 2 hours post the evening dose.

On evening dosing days (Cohort 3 Part 2 Days 1-7): pre-dose and 12 hourspost-dose.

Continuous ECG (cECG)While confined to the unit, subjects will have continuous ECG monitoring(telemetry) for Days 1 and 7 of Compound 9/placebo dosing with cECGrecords printed out every four hours. Any clinically significantabnormalities will be recorded as adverse events, with the correspondingcECG record kept in the source documents for the study.

Columbia-Suicide Severity Rating Scale (C-SSRS)

This scale will be assessed during the MAD cohorts only. The“Baseline/Screening” C-SSRS form will be completed during Screening. The“Since Last Visit” C-SSRS form will be completed on Compound 9/placebodosing day Day 7. See Appendix 4.

Stanford Sleepiness Scale (SSS)

This scale measures level of alertness/sedation, see Appendix 5. Alltime points are relative to the time of dosing. If the planned timepoint is between the hours of approximately 22:00 h and 08:00 h each dayor if the subject has been discharged before the last scheduled timepoint, the assessment need not be conducted at that time point.

On the first and last Compound 9/placebo daytime dosing days in eachcohort (e.g., Cohort 1 Days 1 and 7, and Cohort 4 Days 3 and 9): if oncedaily dosing obtain pre-dose and 1, 2, 4, 6, 8, 12, and 24 hours afterdosing, or if twice daily dosing obtain pre-dose and 1, 2, 4, 6, 8, 12hours after the morning dose, and 1, 2 and 3 hours after the eveningdose.

On all other daytime Compound 9 dosing days: if once daily dosing obtainpre-dose and 1, 4, 8, 12 and 24 hours after dosing, or if twice dailydosing obtain pre-dose and 1, 4, 8, 12 hours after the morning dose and2 and 12 hours after the evening dose.

On Compound 9/placebo evening dosing days (Cohort 3 Part 2, ifapplicable): pre-dose and 1, 2, 3, 12, 14, 16 and 20 hours after dosing.

Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S)

The MOAA/S allows exploration of deeper sedation states than the SSS.All time points are relative to the time of dosing. If the planned timepoint is between the hours of 22:00 h and 08:00 h each day or if thesubject has been discharged before the +72 hour time point, theassessment need not be conducted at that time point. If a subject isdifficult to awaken, an additional MOAA/S assessment may be performed atthe discretion of the PI. Any MOAA score of 3 or less must be repeated.The MOAA/S assessment should be conducted after other assessments thatare scheduled at the same time point. All time points relate to theadministration of study drug.

On the first and last daytime Compound 9/placebo dosing day in eachcohort: if once daily dosing obtain pre-dose and 1, 2, 4, 6, 8 and 12hours after dosing, or if twice daily dosing obtain pre-dose and 1, 2,4, 6, 8 and 12 hours after the morning dose, and 2 hours after theevening dose.

On all other daytime Compound 9/placebo dosing days: if once dailydosing obtain pre-dose and 1, 4, 8, 12 hours after dosing, or if twicedaily dosing obtain pre-dose and 1, 4, 8, 12 hours after the morningdose, and 2 hours after the evening dose.

On evening Compound 9/placebo dosing days (Cohort 3, second dosingperiod): pre-dose and 1, 2, 3, 12, 14, 16, and 20 hours after dosing.

Bond-Lader VAS (Mood Rating Scale)

Mood will be assessed using the Bond-Lader Mood Rating Scale (Appendix7). This is a 16-part self-administered questionnaire that employs 100mm visual analogue scales to explore different aspects of self-reportedmood. The mood scale will be administered at the following time points:

On the first and last daytime Compound 9/placebo dosing (relative Days 1and 7): if once daily dosing obtain pre-dose, and at approximately 2, 4and 12 hours post-dose; or if twice daily dosing obtain pre-dose, and atapproximately 2, 4, 8 and 12 hours post the morning dose, and 2 hourspost the evening dose (post-dose assessment timing may be adjusteddepending on Example 2 SAD Tmax).

On Compound 9 evening dosing Days 1 and 7: pre-dose and approximately 12hours post-dose.

Hospital Anxiety and Depression Scale

Anxiety will be assessed using the Hospital Anxiety and Depression Scale(HADS) (Zigmond and Snaith, 1983) at the following time points:

On the first and last daytime Compound 9/placebo dosing (relative Days 1and 7): if once daily dosing obtain pre-dose, and at approximately 2, 4and 12 hours post-dose; or if twice daily dosing obtain pre-dose, and atapproximately 2, 4, 8 and 12 hours post the morning dose and 2 hourspost the evening dose (post-dose assessment timing may be adjusteddepending on Example 2 SAD Tmax).

On Compound 9/placebo evening dosing Days 1 and 7: pre-dose andapproximately 12 hours postdose.

Blood Sample Collection for Pharmacokinetic Assessments

Plasma samples for analysis of Compound 9 concentrations will becollected at the time points relative to dosing as shown.

The time of study drug administration is time zero and all post-dosingsampling times are relative to dosing time. The investigator willarrange to have the plasma samples processed and transported as directedfor bioanalysis as directed by the Sponsor. Selected samples may beanalyzed for concentrations of metabolites of Compound 9. An additionalsample for analysis of Compound 9 concentrations may be collected at anytime if clinically indicated and at the discretion of the investigator(e.g. for unusual or severe AEs). Samples for CYP induction drugs willbe processed and transported as directed by the Sponsor. Timing forsample draw times may be adjusted for each cohort based on earlier PKresults.

Each sample will be marked with unique identifiers as determined by theCRO and agreed by the Sponsor.

Blood samples for plasma concentrations of Compound 9 should be takenjust prior to any scheduled relaxation epoch when the sample timecoincides with an EEG time point.

Urine Sample Collection for Pharmacokinetic Assessments

During the MAD daytime dosing cohorts (1, 2 and 3 [Part 1]), all voidedurine will be collected and pooled over the following time periods onDay 1 and Day 7: pre-dose; 0-4 hours; 4-8 hours; and 8-12 hours. Asample will be obtained from each pooled sample and processed foranalysis of Compound 9 concentrations. Urine samples may also beanalyzed for Compound 9 metabolite concentrations. The pre-dose urinesample is to be collected just prior to dosing. The post-dose collectionperiods are relative to dosing.

Drug Effects Questionnaire (DEQ-5)

A Drug Effects Questionnaire (DEQ-5) (see Appendix 8) will beadministered as follows:

-   -   1. Do you FEEL a drug effect right now?    -   2. Are you HIGH right now?    -   3. Do you DISLIKE any of the effects that you are feeling right        now?    -   4. Do you LIKE any of the effects that you are feeling right        now?    -   5. Would you like MORE of the drug you took, right now?        -   The answers are recorded on a 100 mm visual analogue scale            with the answer for each being “Not at all” and “Extremely”            at the extremes. There will be options to record “Not            applicable” for questions 3 and 4 if no drug effects are            felt and for question 5 prior to administration of study            medication.            The DEQ5 will be administered at the following time points            during the MAD part of the study: On the first and last            Compound 9/placebo daytime dosing (relative Days 1 and 7):            if once daily dosing obtain pre-dose and 2, 4, 8 and 12            hours post-dose, or if twice daily dosing obtain predose and            2, 4, 8 and 12 hours post the morning dose, and 2 hours post            the evening dose.            On Compound 9/placebo evening dosing days 1 and 7: pre-dose            and 12 hours post-dose.

Psychomotor Testing

Psychomotor testing will be undertaken to assess cognitive function in avariety of domains such as attention, working memory, episodic secondarymemory, executive function, and motor skills. Examples of psychomotortesting include the Detection Task, Identification Task, One CardLearning Task, and Groton Maze Learning Test. The actual tests performedmay vary depending on the vendor chosen. Psychomotor testing will beconducted during the MAD cohorts only.

On Compound 9 daytime dosing days (Day 1 and Day 7): pre-dose and 3hours post-dose (post the morning dose if twice daily dosing).Psychomotor testing will not be performed for Cohort 3 Part 2.EEG with Eye Tracking

Measures of brain electrical activity will indicate any direct impact onthe nervous system and are used as a critical adjunct to behavioralassessment. Findings can be used to investigate subclinical behavioraleffects of Compound 9 and can be easily quantified and compared tochanges in pharmacokinetic measures. The samples will be cleaned forEMG, eye motion, head movement or other non-cerebral artifacts; cleaneddata will then be submitted to power spectral analysis to quantitativelyassess impact on the brain over time. Previous studies with thebenzodiazepine midazolam have shown significant dose-dependent slowingof peak velocity, peak acceleration, peak deceleration, reduced saccadeacceleration/deceleration ratio and saccade accuracy, as well asincreased sedation self-rating. The current study will use measures ofsaccadic velocity to assess sedative effects of Compound 9. An EEG withat least 24 channels set for continuous recording will be appliedapproximately 1 hour prior to dosing and kept in place for approximately9 hours after dosing for subjects participating in MAD cohorts 1, 2 and3 (Part 1 only) on Days 1 and 7. EEG relaxation epochs and eye trackingwill completed at approximately 30 minutes pre-dose and at approximately2 and 8 hours post-dose. The post-dose assessment timing may be adjusteddepending on earlier PK results from the SAD study Example 2 or previousMAD cohorts. During the relaxation epochs subjects are asked to closetheir eyes, relax and empty their minds of thoughts. Eye tracking willbe assessed at the same time as the EEG is being recorded.

Sleep Questionnaire

A 6-item subject-rated sleep quality questionnaire created for internaluse will be administered to subjects in Cohort 3 Part 2 (nighttimedosing) upon awakening in the morning the mornings of Days 16 to 22.

Window Allowance Document

A “Window Allowance Document” document will be prepared which willoutline acceptable windows for intervals between nominal times andactual times for study procedures, e.g. ±5 minutes for PK samplingtimes. This will allow flexibility when multiple procedures arescheduled for the same time point, e.g., PK sampling and vital signsboth taken at “1 h after dosing”.

Adverse Event (AE)

An AE is the development of an undesirable medical condition or thedeterioration of a pre-existing medical condition following or duringexposure to a pharmaceutical product, whether or not considered casuallyrelated to the product. In clinical studies, an AE can include anundesirable medical condition occurring at any time, including baselineor washout periods, even if no study treatment has been administered.

All AEs that occur after any subject/subject has been enrolled, beforetreatment, during treatment, or within 14 days following the cessationof treatment, whether or not they are related to the study, must berecorded on forms provided by designee.

Serious Adverse Event (SAE)

A serious adverse event is an AE occurring during any study phase (i.e.,baseline, treatment, washout, or follow-up), and at any dose of theinvestigational product, comparator or placebo, that fulfils one or moreof the following:

-   -   Results in death    -   It is immediately life-threatening    -   It requires in-subject hospitalization or prolongation of        existing hospitalization    -   It results in persistent or significant disability or incapacity    -   Results in a congenital abnormality or birth defect    -   It is an important medical event that may jeopardize the subject        or may require medical intervention to prevent one of the        outcomes listed above.        All SAEs that occur after any subject/subject has been enrolled,        before treatment, during treatment, or within 28 days following        the cessation of treatment, whether or not they are related to        the study, must be recorded on forms provided by designee.

Recording Sedation as an Adverse Event

Sedation will be assessed using specific rating scales in this study. Inorder to apply consistency to adverse event reports of sedation andtaking into consideration the frequent assessment of sedation using thescoring scales, Investigators need not record sedation as an adverseevent unless there is a score of ≥5 on the SSS and/or a score of ≤2 onthe MOAA/S. Consideration should be given to the most appropriate termto describe the sedation characteristics.

Relationship to Study Drug

An Investigator who is qualified in medicine must make the determinationof relationship to the investigational product for each AE (Unrelated,Possibly Related or Probably Related). The Investigator should decidewhether, in his or her medical judgment, there is a reasonablepossibility that the event may have been caused by the investigationalproduct. If no valid reason exists for suggesting a relationship, thenthe AE should be classified as “unrelated.” If there is any validreason, even if undetermined, for suspecting a possible cause-and-effectrelationship between the investigational product and the occurrence ofthe AE, then the AE should be considered “related.”

Not Related: No relationship between the experience and theadministration of study drug; related to other etiologies such asconcomitant medications or subject's clinical state.Possibly Related: A reaction that follows a plausible temporal sequencefrom administration of the study drug and follows a known responsepattern to the suspected study drug.The reaction might have been produced by the subject's clinical state orother modes of therapy administered to the subject, but this is notknown for sure.Probably Related: A reaction that follows a plausible temporal sequencefrom administration of the study drug and follows a known responsepattern to the suspected study drug.

The reaction cannot be reasonably explained by the known characteristicsof the subject's clinical state or other modes of therapy administeredto the subject.

If the relationship between the AE/SAE and the investigational productis determined to be “possible” or “probable” the event will beconsidered to be related to the investigational product for the purposesof expedited regulatory reporting.

Recording Adverse Events

Adverse events spontaneously reported by the subject/subject and/or inresponse to an open question from the study personnel or revealed byobservation will be recorded during the study at the investigationalsite. Clinically significant changes in laboratory values, bloodpressure, and pulse need not be reported as AEs unless they promptcorrective medical action by the Investigator, constitute an SAE or leadto discontinuation of administration of study drug.

Information about AEs will be collected from the signing of the consentform until the final visit of the study for that subject. Adverse eventsthat occur after the first administration of study drug will be denotedTreatment Emergent Adverse Events.

All AEs will be followed until they are resolved or have reached aclinical plateau with no expectation of future change.

The AE term should be reported in standard medical terminology whenpossible. For each AE, the Investigator will evaluate and report theonset (date and time), resolution or clinical plateau (date and time),intensity, causality, action taken, outcome, and whether or not itcaused the subject to discontinue the study.

Intensity will be assessed according to the following scale:

-   -   Mild (awareness of sign or symptom, but easily tolerated)    -   Moderate (discomfort sufficient to cause interference with        normal activities)    -   Severe (incapacitating, with inability to perform normal        activities)

Reporting Serious Adverse Events

All SAEs (regardless of causality) will be recorded from the signing ofthe consent form until 28 days following the last dose of study drug.Any SAEs considered possibly or probably related to the investigationalproduct and discovered by the Investigator at any time after the studyshould be reported. All SAEs must be reported to the Sponsor orSponsor's designee immediately by phone and in writing within 24 hoursof the first awareness of the event.

Safety Analysis

For all safety analyses of the MAD portion of the study, the placebodose group will be pooled across cohorts. AEs will be coded usingMedDRA™ with the version used specified in the clinical study report.The overall incidence of AEs will be displayed by System Organ Class(SOC), preferred term, and dose group. Incidence of AEs will also bepresented by maximum severity and relationship to study drug. Data fromvital signs, clinical laboratory measures, ECG, and C-SSRS will besummarized using descriptive statistics by dose group and time point,where applicable.

Continuous endpoints will be summarized with n, mean, standarddeviation, median, minimum and maximum. In addition, change frombaseline values will be calculated at each time point and will besummarized using descriptive statistics. Out-of-range safety endpointsmay be categorized as low or high, where applicable. For all categoricalendpoints, summaries will include counts and percentages.

Pharmacokinetic Analysis

Derived PK parameters will include area under the plasma concentrationcurve (AUC0-inf), the distribution half-life and terminal half-life(t½), the maximum concentration (Cmax), the time to reach maximumconcentration (Tmax), and the clearance (CL) and urine excretion. PKparameters will be summarized using appropriate descriptive statistics.Time to reach maximum concentration (Tmax) will be summarized using n,median, minimum, and maximum. All other PK parameters will be summarizedusing n, geometric mean, coefficient of variation, median, minimum, andmaximum.

Dose proportionality of Compound 9 will be analyzed using a linearregression model with the logarithm of PK parameter (AUC and Cmax) asthe dependent variable and the logarithm of the dose as the independentvariable. Point estimates of the slope coefficient and the correspondingCIs will be provided for both AUC and Cmax.

Exemplary Pharmacokinetic Sampling Schedule

TABLE 10 MAD Cohorts PK Sampling Schedule (times in hours relative todosing) Formula I MAD Cohorts 1, 2, and 3 (Part 1) Formula I DaytimeDosing Formula I Follow up (Days 1 and 7) (Day 8) Pre-Dose 0.25 0.5 11.5 2 3 4 6 8 10 12 16* 24* 28 32 36 48 Formula I MAD Evening Dosing(Cohort 3 Part 2) (If applicable) Formula I Evening Dosing Formula IFollow up (Days 1 and 7) (Day 8) Pre-Dose 0.25 0.5 1 1.5 2 3 12 16 24 3648 *If dosing BID, obtain on Day 7 only.

TABLE 11 DDI Cohort PK Sampling Schedule (times in hours relative todosing) Days 1 and 2 CYP Induction Drugs Prior to Formula I Dosing:Simvastatin (Day 1) and Bupropion (Day 2) Pre-Dose 1 2 3 4 5 6 8 10 1216 24 Days 3-9 Formula I Dosing: Formula I Daytime Dosing Formula IFollow-Up (Days 3 and 9) (Day 10) Pre-Dose 0.25 0.5 1 1.5 2 3 4 6 8 1012 16 24 28 32 36 48 Days 10 and 11 CYP Induction Drugs FollowingFormula I Dosing: Bupropion (Day 10) and Simvastatin (Day 11) Pre-Dose 12 3 4 5 6 8 10 12 16 24

Drug-Drug Interaction (DDI) Analysis

To evaluate the effect of administration of Compound 9 on the plasma PKprofile of the test drug simvastatin and the test drug bupropion, PKparameters for AUC and Cmax for simvastatin and bupropion will benatural log-transformed and evaluated using a linear mixed effects modelwith fixed effects terms for treatment. An unstructured covariancematrix will be used to allow for unequal treatment variances and tomodel the correlation between the treatment measurements within eachsubject via the REPEATED statement in SAS PEOC MIXED. Kenward andRoger's method will be used to calculate the denominator degrees offreedom for the fixed effects (DDFM=KR).

A ninety percent (90%) confidence interval (CI) will be constructed forthe difference in least squares means on the log scale for each of AUCand Cmax. Exponentiating the log-scale 90% CI will provide a 90% CI forthe geometric mean ratios (simvastatin+Compound 9/simvastatin alone orbupropion+Compound 9/bupropion alone).

Further details of the above DDI analysis will be provided in thestatistical analysis plan.

Other Endpoint Analyses

The secondary endpoints of SSS, MOAA/S, BL-VAS, HADS, and DEQ-5 valuesand the exploratory sleep quality data will be summarized using the samedescriptive statistics described above for the safety variables. Thepharmacodynamics analysis of EEG endpoints and their relationship topsychomotor testing and eye tracking measures will be described in aseparate analysis plan. In addition, PK/PD exploratory analyses will beperformed utilizing sedation, mood, anxiety, depression, EEG andpsychomotor data. Sleep quality will be assessed by a selfadministeredsleep questionnaire PK/PD analysis will consist of descriptive figuresplotting PK concentrations versus numeric ratings or scores associatedwith SSS, MOAA/S, BL-VAS, HADS and DEQ-5 outcomes.

TABLE 12 Cohorts 1, 2 and 3 Part 1 Schedule of Events Cohorts 1 and 2Visit V1 V2 V3 V4 V5 V6 V7 V8 Visit Window V2 − V3 − 0 +24 +48 +72 +96+120 1-28 d 1 d h-+24 h h-+48 h-+72 h h-+96 h h-+120 h h-+144 h VisitDays Screen Admit D 1 D 2 D 3 D 4 D 5 D 6 Informed Consent XInclusion/Exclusion X X Demographics X Medical History X PhysicalExamination X Body Weight/Height X CBC/Serum Chemistry X X X UrinalysisX X X Drug/Alcohol Screen X X Hepatitis & HIV Screen X Genetic Sample XVital Signs¹ X X X X X X X X 12-Lend ECG² X X X X X X X X cECG³ XC-SSRS⁴ X SSS⁵ X X X X X X MOAA/S⁵ X X X X X X DEQ5⁶ X Bond-Lader MoodScore⁷ X HADS⁸ X Psychomotor Testing⁹ X EEG & Eye Tracking¹⁰ X Plasma PKSamples¹¹ X Urine PK Samples¹² X Confined to Unit X X X X X X XAdminister Formulation 1¹³ X X X X X X Adverse Events X X X X X X XCohorts 1 and 2 Visit V9 V10 V11 V12 V13 V14 Visit Window +144 +168 +196+220 V9 + 7 d V9 + 14 d h-+168 h h-+196 h h-+220 h h-+244 h (±1 d) (±1d) Visit Days D 7 D 8 D 9 D 10 Follow Up Study End Informed ConsentInclusion/Exclusion Demographics Medical History Physical Examination XBody Weight/Height CBC/Serum Chemistry X Wt only X Urinalysis X XDrug/Alcohol Screen Hepatitis & HIV Screen Genetic Sample Vital Signs¹ XX X X X 12-Lend ECG² X X X X X cECG³ C-SSRS⁴ SSS⁵ X MOAA/S⁵ X DEQ5⁶ XBond-Lader Mood Score⁷ X HADS⁸ X Psychomotor Testing⁹ X EEG & EyeTracking¹⁰ X Plasma PK Samples¹¹ X X Urine PK Samples¹² X Confined toUnit X X X X Administer Formulation 1¹³ X Adverse Events X X X X X XCohorts 1 and 2 Visit V1 V2 V3 V4 V5 V6 V7 V8 V9 V10 V11 V12 V13 V14Concomitant Meds X X X X X X X X X X X X X X If discrepancies are notedbetween the Schedule of Events and the text sections, the text sectionstake precedence.

TABLE 13 Cohort 3 Part 2 Schedule of Events This Schedule of Events(SoE) assumes QD dosing; if dosing is BID then this SoE is not needed.Cohort 3 Part 2 Visit V13 V14 V15 V16 V17 V18 V19 V20 Visit Window V14 −0 +24 +48 +72 +96 +120 +144 1 d h-+24 h h-+48 h-+72 h h-+96 h h-+120 hh-+144 h h-+168 h Visit Days D 14 Admit D 15 D 16 D 17 D 18 D 19 D 20 D21 Informed Consent Inclusion/Exclusion Demographics Medical HistoryPhysical Examination Body Weight/Height X Wt only CBC/Serum Chemistry XX X Urinalysis X X X Drug/Alcohol Screen X Vital Signs¹ X X X X X X X X12-Lend ECG² X X X X X X X X cECG³ X X X C-SSRS⁴ X SSS⁵ X X X X X X XMOAA/S⁵ X X X X X X X DEQ⁶ Bond Lader Mood Score⁶ X X HADS⁶ X X PlasmaPK Samples⁷ X X Sleep Quality Questionnaire⁸ X X X X X X Confined toUnit X X X X X X X X Administer Formula 1 X X X X X X X Cohort 3 Part 2Visit V21 V22 V23 V24 V25 Visit Window +168 +196 +220 V20 + V20 + h-+196h h-+220 h h-+244 h 7 d (±1 d) 14 d (±1 d) Visit Days D 22 D 23 D 24Follow Up Study End Informed Consent Inclusion/Exclusion DemographicsMedical History Physical Examination X Body Weight/Height CBC/SerumChemistry X Urinalysis X Drug/Alcohol Screen Vital Signs¹ X X X 12-LendECG² X X X X cECG³ C-SSRS⁴ SSS⁵ MOAA/S⁵ DEQ⁶ Bond Lader Mood Score⁶HADS⁶ Plasma PK Samples⁷ X X X Sleep Quality Questionnaire⁸ X Confinedto Unit X X X Administer Formula 1 Cohorts 3 Part 2 Visit V13 V14 V15V16 V17 V18 V19 V20 V21 V22 V23 V24 V25 Adverse Events X X X X X X X X XX X X X Concomitant Meds X X X X X X X X X X X X X If the protocol textand Schedule of Events differ, the protocol text takes precedence.*Visit days may be adjusted if washout period duration of 7 days isadjusted. By the SRC.

TABLE 14 Cohort 4 Schedule of Events Visit V1 V2 V3 V4 V5 V6 V7 V8 V9Visit Window V2 − V3 − 0 +24 +48 +72 +96 +120 +144 1-28 d 1 d h-+24 hh-+48 h-+72 h h-+96 h h-+120 h h-+144 h h-+168 h Visit Days Screen AdmitD 1 D 2 D 3 D 4 D 5 D 6 D 7 Informed Consent X Inclusion/Exclusion XDemographics X Medical History X Physical Examination X BodyWeight/Height X CBC/Serum Chemistry X X X Urinalysis X X X Drug/AlcoholScreen X X Hepatatis & HIV X Screen Genetic Sample X Vital Signs¹ X X XX X X X X X 12-Lend ECG² X X X X X X X X X cECG³ X SSS⁴ X X X X XMOAA/S⁵ X X X X X Plasma PK X X X Samples⁶ Confined to Unit X X X X X XX X Administer X X X X X Formula 1 Induction Test Drug X X AdverseEvents X X X X X X X X Concomitant Meds X X X X X X X X X Visit V10 V11V12 V13 V14 V15 V16 Visit Window +168 +196 +220 +244 +268 h-+196 hh-+220 h h-+244 h h-+268 h h-+282 h V11 + 7 d V11 + 14 d Visit Days D 8D 9 D 10 D 11 D 12 Follow Up Study End Informed ConsentInclusion/Exclusion Demographics Medical History Physical Examination XBody Weight/Height CBC/Serum Chemistry X X Wt only Urinalysis X XDrug/Alcohol Screen Hepatatis & HIV Screen Genetic Sample Vital Signs¹ XX X X X X 12-Lend ECG² X X X X X X cECG³ X SSS⁴ X X X X MOAA/S⁵ X X X XPlasma PK X X Samples⁶ Confined to Unit X X X X X Administer X X Formula1 Induction Test Drug X X Adverse Events X X X X X X X Concomitant MedsX X X X X X X If the protocol text and Schedule of Events differ, theprotocol takes precedence.

Example 4. A Double-Blind, Randomized, Placebo-Controlled, Phase 2Registration Study of Brexanolone in 21 Hospital Inpatient Women withSevere PPD Materials and Methods Study Design and Participants

This multicenter, randomized, double-blind, parallel-group,placebo-controlled trial (NCT02614547) was conducted at 11 sites in theUnited States with IRB approval from each study site. Sage Therapeutics,Inc. collaborated with the principal investigator (SMB) in the design ofthe trial and all investigators in the execution of the trial andcollection of data. All authors vouch for the accuracy and completenessof the data, data analyses, and the fidelity of this report to the studyprotocol. Additional study conduct details are provided in theSupplementary Appendix.

Study Population

Enrollment required written informed consent. Eligible subjects wererequired to have had a major depressive episode that began no earlierthan the third trimester and no later than the first four weeksfollowing delivery and to be within six months postpartum at the time ofenrollment. PPD diagnoses were confirmed by the Structured ClinicalInterview for DSM-W Axis I Disorders (SCID-I). Enrollment required a17-item Hamilton Rating Scale for Depression (HAM-D) total score of ≥26.Subjects remained as in-patients during the 60-hour study infusionperiod.

Exclusion criteria included: active psychosis; attempted suicideassociated with index case of PPD; history of seizures, bipolardisorder, schizophrenia and/or schizoaffective disorder, and/oralcoholism or drug addiction (including benzodiazepines) in the 12months prior to screening. Additional inclusion/exclusion details areavailable in the Supplementary Appendix.

Randomization and Masking

Each subject was provided the next randomization number in sequence by ablinded study monitor. Subjects were then randomized, according to acomputer-generated randomization schedule, 1:1 to brexanolone orplacebo. The randomization schedule was produced by an independentstatistician at Applied Statistics and Consulting (Spruce Pine, NC).Subjects, clinicians, and study teams were blinded to treatmentallocation. Subjects in the placebo group received equivalent infusionrates, and both treatments were identical in appearance. The pharmacistat each site, who prepared the infusion bags according to therandomization schedule, and an unblinded monitor, who performed drugaccountability during the study, were unblinded. No other studypersonnel were unblinded until after formal locking of the studydatabase. Only the clinic pharmacist was given a copy of therandomization schedule. In the event of a medical emergency, thepharmacist was to reveal actual infusion contents to the primaryinvestigator, who was to alert the Sponsor of the emergency. In allcases, if the study drug allocation for a subject had been unblinded,pertinent information (including the reason for unblinding) was to bedocumented in the subject's records and on the eCRF. If the subject orstudy center personnel were unblinded, the subject was to be terminatedfrom the study. No such unblinding occurred during the study.

Procedures

Brexanolone is a sterile solution of 5 mg/mL allopregnanolone in 250mg/mL sulfobutylether-β-cyclodextrin (SBECD) buffered with citrate,which is diluted with sterile water for injection to render it isotonicfor IV infusion. Each subject received a single continuous W infusion ofblinded study drug for 60 hours during inpatient care under thefollowing schedule: 30 μg/kg/hour (0-4 hours); 60 μg/kg/hour (4-24hours); 90 μg/kg/hour (24-52 hours); 60 μg/kg/hour (52-56 hours); 30μg/kg/hour (56-60 hours). Infusion rate adjustments were allowed basedon tolerability, side effects, and pre-determined protocol rules. Dosingwas based on both a prior open-label exploratory trial in PPD (Kanes etal., 2016; Human Psychopharmacology, in press) and on pharmacokinetic(PK) modelling. After dosing was complete, subjects were followedthrough Day 30, with clinical and safety assessments obtained at 7 and30 days.

Outcomes

The primary outcome measure was the change from baseline in the HAM-Dtotal score (brexanolone vs. placebo) at the end of the treatment period(60 hours). Secondary analyses included changes in the HAM-D frombaseline at 2 hours through 30 days. Secondary HAM-D endpoints includedremission rates (total score ≤7), response rates (≥50% reduction intotal score), change from baseline in the Bech-6 subscore, whichassesses the core symptoms of major depression, and changes in the HAM-DDepressed Mood Item Score. Additional, pre-specified secondary andexploratory endpoints are detailed in Table 17, including the MontgomeryÅsberg Depression Rating Scale (MADRS) Total Score, Clinical GlobalImpression-Global Improvement (CGI-I), Generalized Anxiety DisorderQuestionnaire (GAD-7), Edinburgh Postnatal Depression Scale (EPDS),Patient Health Questionnaire-9 (PHQ-9), and Barkin Index of MaternalFunction (BIMF).

The safety and tolerability of brexanolone were evaluated by collectingand summarizing adverse events (AEs), clinical laboratory measures,vital signs, and ECGs (including changes from baseline); concomitantmedication usage was also assessed. Emergent suicidal ideation andbehaviors were assessed using the Columbia-Suicide Severity Rating scale(C-SSRS); subject-reported sedation/sleepiness was assessed using theStanford Sleepiness Scale (SSS). Plasma was collected to assay forallopregnanolone, allopregnanolone metabolites, and SBECD.

Statistical Analysis

The Safety Population included all randomized subjects who startedinfusion of study drug or placebo. The Efficacy (EFF) Populationincluded the subset of the Safety Population who had a completedbaseline HAM-D assessment and at least one post-baseline HAM-Dassessment. The change from baseline in HAM-D and MADRS total score wasanalyzed using a mixed effects model for repeated measures (MMRM). Themodel included center, treatment, baseline HAM-D total score, assessmenttime point, and time point-by-treatment as explanatory variables. Centerwas treated as a random effect, while all other explanatory variableswere treated as fixed effects. Model based point estimates (i.e., LSmeans, 95% confidence intervals, and p-values) were reported for eachtime point. The primary comparison was between brexanolone and placeboat the 60-hour time point. Other changes from baseline endpoints wereanalyzed using similar methods. The HAM-D response and remission ratesat each time point were analyzed using Fisher's Exact Test. Model-basedpoint estimates (i.e., odds ratios), 95% confidence intervals, andp-values were reported.

Assuming a two-sided test at an alpha level of 0·10, a sample size of 10evaluable subjects per group provided 80% power to detect an effect sizeof 1·2 between the brexanolone and placebo groups with regard to theprimary outcome variable of change from baseline in HAM-D total score.An effect size of 1·2 corresponds to a placebo-adjusted difference of 12points in the change from baseline in HAM-D total score at 60 hours withan assumed standard deviation of ten points. By including two treatmentgroups and using a 1:1 randomization ratio, a total of 20 evaluablesubjects were required. Based on the results of the interim analysis,the sample size could have been increased to a maximum of 32 randomizedsubjects. This adjustment to the sample size would have allowed for aneffect size of 1·0 to be detected.

Results

Twenty-three subjects with severe PPD (HAM-D≥26) enrolled in this study,which was conducted from Dec. 15, 2015 to May 19, 2016. Twenty-one weresubsequently randomized (10 brexanolone, 11 placebo), and all completedthe 60-hour in-patient dosing protocol and full trial (FIG. 10 , Table15). The mean age (SD) was 28·8 (4·58) for placebo and 27·4 (5·34) forbrexanolone groups. The percentage of subjects with a prior history ofpsychiatric conditions was comparable between treatment groups, with theexception of anxiety (20·0% brexanolone, 45·5% placebo). The percentageof subjects with at least one previous episode of PPD was 36.3% in theplacebo group treatment group and 70·0% in the brexanolone group.Antidepressant medication use was balanced between the brexanolone andplacebo treatment groups (30·0% and 27·3%, respectively). Demographiccharacteristics are summarized in Table 15.

The primary endpoint was achieved; at the end of the 60-hour infusion,brexanolone-treated subjects demonstrated a mean reduction in HAM-Dtotal score of 20·97 points, a 12·2 [95% CI, −3·67 to −20·77] pointdifference from placebo (p=0·008). Pre-specified secondary analysesdemonstrated an 11·9 [−3·65 to −18·86] point mean difference at 24 hours(p=0·006), with statistically significant improvements also observed forthe brexanolone group at 36, 48, and 72 hours, as well as Days 7 and 30(FIG. 11 ). The effect size for the clinical efficacy of brexanolone at60 hours was 1·2, and the effect was statistically significant by 24hours. Assessment using the MADRS total score and change from baselineshowed similar results to those obtained using HAM-D (FIGS. 11A, 11B andTable 16).

Remission from depression (HAM-D≤7) was observed in 7 of 10brexanolone-treated subjects and 1 of 11 placebo-treated subjects at 60hours (OR-23·33; CI-1·56, 1152·71, p=0·008; FIG. 12 ). This differencewas observed at 24 hours (1 placebo vs. 6 brexanolone; OR 15, 95% CI1·07 to 756·72, p=0·024) and a difference was maintained through the30-day follow-up (2 placebo vs. 7 brexanolone; OR 10·, 95% CI 1·01 to140·57, p=0·030). Additional secondary measures and categorical responsemeasures were supportive of the primary endpoint of the trial, showingimprovements in favor of brexanolone relative to placebo (Table 17).

Brexanolone was generally well tolerated. There were no deaths, seriousadverse events (SAEs), or discontinuations. Overall, fewer subjects whoreceived brexanolone experienced AEs compared with placebo (4 of 10subjects on brexanolone and 8 of 11 subjects on placebo; Table 18). Themost commonly reported AEs in the brexanolone group were dizziness (2brexanolone-treated subjects; 3 placebo-treated subjects) and somnolence(2 brexanolone-treated subjects; 0 placebo-treated subjects). Sedationwas reported in one brexanolone-treated subject and in noplacebo-treated subjects.

At baseline, mean SSS scores were similar in the brexanolone and placebogroups (2·7 vs. 2·6) as measured by SSS. There were no differences insleepiness between treatment groups. One subject who was taking astanding clonazepam dose (6 mg) experienced sleepiness on brexanolone,requiring dose reduction of the study drug and, after dose reduction,completed participation in the study (Table 19).

Improvements in C-SSRS suicidal ideation items were noted in bothtreatment groups; of note, two subjects in the brexanolone groupreported active suicidal ideation with a specific plan and intent atbaseline but not at the post-treatment assessment. No individualsexperienced worsening of suicidal ideation or behavior during thetreatment or follow-up period (Table 20).

This trial demonstrates that a study of postpartum, lactating, depressedwomen with PPD is feasible and that complex trial designs are notnecessarily required to overcome presumed placebo responses, especiallywith the large effect size we observed with brexanolone. Furthermore,trials in such a clearly defined and previously understudied patientpopulation are crucial to develop novel treatments for PPD. Due to thelarge effect size and rapid response, the study was adequately powered,with remission durable in the treatment group to at least 30 days posttreatment.

TABLE 15 Demographics and Characteristics. Demographic parametersincluded date of birth, age, race, and ethnicity. Age was derived fromthe birth date and screening date. Body weight and height were measuredat screening. Body mass index was programmatically calculated in theeCRF. Medical histories were coded according to the Medical Dictionaryfor Regulatory Activities (MedDRA) version 17 or higher. SD = standarddeviation. Demographics and Characteristics Characteristics PlaceboBrexanolone Overall Age Mean 28.8 27.4 28.1 SD 4.6 5.3 28.1 Median 28 2727 Sex Male 0 0 0 Female 11 10 21 Ethnicity Hispanic or Latino 0 0 0 NotHispanic 11 10 21 or Latino Black or African Race American 6 7 13 White5 3 8 Height (cm) Mean 161.7 162.4 162.0 SD 6.7 7.1 6.7 Median 162.0163.5 162.0 Weight (kg) Mean 77.0 86.7 81.6 SD 22.3 28.8 25.4 Median73.5 76.5 73.9 BMI (kg/m²) Mean 29.3 32.7 30.9 SD 7.8 9.9 8.8 Median28.2 30.5 30.1 Personal history Psychiatric Disorder Depression 6 12(non-PPD) (54.5%) 6 (60.0%) (57.1%) Anxiety 5 2 7 (45.5%) (20.0%)(33.3%) Other 2 1 3 (18.2%) (10.0%) (14.3%) Prior PPD episodes 4 7 11(36.4%) (70.0%) (52.3%) Family history Perinatal Psychiatric Mother 2 24 Conditions (18.2%) (20.0%) (19.0%) Sister(s) 1 (9.1%) 1 (10.0%) 2(9.5%)

TABLE 16 Study Drug vs. Placebo, HAM-D and MADRS Total Score Change FromBaseline. The changes from baseline for HAM-D and MADRS mean totalscores are summarized. The change from baseline of the HAM-D mean totalscore and MADRS mean total score was analyzed using a mixed effectsmodel for repeated measures. MADRS was not assessed at 2, 4, 8, 12, or36 hours. Table 16: Study Drug vs. Placebo, Differences in HAM-D andMADRS scores HAM-D (SE) p-value MADRS (SE) p-value Hour 2 −2.16 2.3420.369 Hour 4 −3.47 2.905 0.248 Hour 8 −4.64 3.131 0.155 Hour 12 −6.013.656 0.116 Hour 24 −11.26 3.636 0.006 −17.53 5.363 0.004 Hour 36 −11.974.026 0.008 Hour 48 −12.67 3.959 0.005 −18.4 5.287 0.003 Hour 60 −12.224.081 0.008 −15.86 5.536 0.010 Hour 72 −12.68 4.272 0.008 −16.2 5.5250.009 Day 7 −12.91 3.907 0.004 −15.96 5.448 0.009 Day 30 −11.93 4.1290.010 −15.07 5.213 0.010 SE = standard error.

TABLE 17 Efficacy Measures, Change from Baseline at Day 30. HAM-D:Hamilton Rating Scale for Depression. MADRS: Montgomery-ÅsbergDepression Rating Scale. CGI-I: Clinical Global Impression- Improvement.GAD-7: Generalized Anxiety Disorder 7-item Scale. EPDS: EdinburghPostnatal Depression Scale. PHQ-9: Patient Health Questionnaire. BIMF:Barkin's Index of Maternal Functioning. All baseline calculations basedon a mixed effects model for repeated measures (MMRM). EfficacyMeasures, Change from Baseline at Day 30 Measure Placebo Brexanolonep-value HAM-D Total Score −9.2 −20.4 0.010 HAM-D Bech 6 Subscale Score−3.5 −10.0 0.018 HAM-D Depressed Mood Item Score −1.2 −2.3 0.080 MADRSTotal Score −11.3 −26.2 0.010 GAD-7 Total Score −8.1 −8.7 0.470 EPDSTotal Score −5.3 −13.5 0.024 PHQ-9 Total Score −8.3 −11.0 0.470 BIMFTotal Score 12.1 24.4 0.240 BIMF Mom's Competency Subscore 4.9 8.0 0.390BIMF Mom's Needs Subscore 5.1 11.9 0.450 Categorical Response Measures,Day 30 CGI-I response (1 or 2) 3 (27.3%) 8 (80.0%) 0.030 GAD-7 minimalanxiety (0 to 4) 1 (9.1%) 6 (60.0%) 0.024 PHQ-9 minimal to no 1 (9.1%) 6(60.0%) 0.024 depression (0 to 4)

TABLE 18 Treatment Emergent Adverse Events in at Least 1 BrexanoloneSubject: A TEAE was defined as an AE with onset after the start of studydrug, or any worsening of a pre-existing medical condition/AE with onsetafter the start of study drug and until the Day 7 follow-up visit (ie,approximately 4 days after the end of the infusion). AEs were codedaccording to MedDRA ® version 18.0. Treatment Emergent Adverse Events inat Least 2 Subjects in Either Group Placebo (N = 11), Brexanolone (N =10), Number Number of Subjects Adverse Event of Subjects ReportingReporting Any AE 8 4 Dizziness 3 2 Somnolence 0 2 Nausea 3 1 AbnormalDreams 2 0 Headache 2 0 Infusion Site Pain 2 0 Insomnia 2 0

TABLE 19 Stanford Sleepiness Scale. The Stanford Sleepiness Scale (SSS)was administered to monitor sedation. Although greater mean increasesfrom baseline in SSS score were noted in the brexanolone group comparedwith the placebo group, none of the treatment group differences wereclinically or statistically significant. 1 = Feeling active, vital,alert, or wide awake; 2 = Feeling active, vital, alert, or wide awake; 3= Awake, but relaxed; responsive but not fully alert; 4 = Somewhatfoggy, let down; 5 = Foggy; losing interest in remaining awake; sloweddown; 6 = Sleepy, woozy, fighting sleep; prefer to lie down, 7 = Nolonger fighting sleep, sleep onset soon; having dream-like thoughts, X =Asleep. Stanford Sleepiness Scale Time (hours) Mean Placebo (n = 11)Mean Brexanolone (n = 10) 0 2.6 2.7 2 3 2.8 4 2.3 3 8 2.6 2.2 12 2.5 3.624 2.6 1.9 30 1.4 2 36 2.1 2 48 1.8 1.5 54 1.5 1.3 60 2 1.4 72 1.7 1.4

TABLE 20 Columbia Suicide Severity Rating Scale: Suicidality wasmonitored during the study using the C-SSRS. This scale consists of apre-dose evaluation that assesses the lifetime and recent experience ofthe subject with suicidal ideation and behavior, and a post-baselineevaluation that focuses on suicidality since the last study visit.Columbia Suicide Severity Rating Scale Pre-treatment Post-treatmentPlacebo Brexanolone Placebo Brexanolone (N = 11) (N = 10) (N = 11) (N =10) Sucicidal Wish to be dead 2 3 2 2 ideation Non-specific 1 3 0 2active sucicidal thoughts Active suicidal 2 2 0 1 ideation with anymethods (not plan) without intent to act Active suicidal 1 2 0 0ideation with some intent to act, without specific plan Active suicidal0 2 0 0 ideation with specific plan and intent Sucicidal Actual attempt0 0 0 0 behavior Has subject 2 1 0 0 engaged in non-suicidalself-injurious behavior

Example 5. Effects of Brexanolone or Placebo on Mean HAM-D Total Score(FIG. 11A) and Mean MADRS Total Score (FIG. 11B) Over Time in the StudyDescribed in Example 4

For panel A: mean total score was assessed for the HAM-D at each timepoint and in Day 7 and Day 30 follow-ups, as indicated. The HAM-D is a17-item diagnostic questionnaire used to measure the severity ofdepressive episodes in patients with mood disorders. It is comprised ofindividual ratings related to the following symptoms: depressed mood(sadness, hopeless, helpless, worthless), feelings of guilt, suicide,insomnia (early, middle, late), work and activities, retardation(slowness of thought and speech; impaired ability to concentrate;decreased motor activity), agitation, anxiety (psychic and somatic),somatic symptoms (gastrointestinal and general), genital symptoms,hypochondriasis, loss of weight, and insight. Higher HAMD-D scoresindicate more severe depression. For panel B: mean total score wasassessed for the MADRS at each time point and in Day 7 and Day 30follow-ups, as indicated. The MADRS is a ten-item diagnosticquestionnaire used to measure the severity of depressive episodes inpatients with mood disorders. Higher MADRS scores indicate more severedepression, and each item yields a score of 0 to 6, producing totalscore ranges from 0 to 60. * denotes statistical significance versusplacebo, *=p≤0.01.

Example 6. HAM-D Remission Rates Over Time in the Study Described inExample 4 (FIG. 12)

Remission was defined as having a HAM-D total score of ≤7. The remissionrates at each time point were calculated. A larger percentage ofsubjects in the brexanolone group than the placebo group achieved HAM-Dremission at each time point after +2 hours. The difference wasstatistically significant at 24 (p=0.024), 48 (p=0.030), 60 (p=0.008),and 72 hours (p=0.030), as well as Days 7 (p=0.003) and 30 (p=0.030).

EQUIVALENTS AND SCOPE

In the claims articles such as “a,” “an,” and “the” may mean one or morethan one unless indicated to the contrary or otherwise evident from thecontext. Claims or descriptions that include “or” between one or moremembers of a group are considered satisfied if one, more than one, orall of the group members are present in, employed in, or otherwiserelevant to a given product or process unless indicated to the contraryor otherwise evident from the context. The invention includesembodiments in which exactly one member of the group is present in,employed in, or otherwise relevant to a given product or process. Theinvention includes embodiments in which more than one, or all of thegroup members are present in, employed in, or otherwise relevant to agiven product or process.

Furthermore, the invention encompasses all variations, combinations, andpermutations in which one or more limitations, elements, clauses, anddescriptive terms from one or more of the listed claims is introducedinto another claim. For example, any claim that is dependent on anotherclaim can be modified to include one or more limitations found in anyother claim that is dependent on the same base claim. Where elements arepresented as lists, e.g., in Markush group format, each subgroup of theelements is also disclosed, and any element(s) can be removed from thegroup. It should it be understood that, in general, where the invention,or aspects of the invention, is/are referred to as comprising particularelements and/or features, certain embodiments of the invention oraspects of the invention consist, or consist essentially of, suchelements and/or features. For purposes of simplicity, those embodimentshave not been specifically set forth in haec verba herein. It is alsonoted that the terms “comprising” and “containing” are intended to beopen and permits the inclusion of additional elements or steps. Whereranges are given, endpoints are included. Furthermore, unless otherwiseindicated or otherwise evident from the context and understanding of oneof ordinary skill in the art, values that are expressed as ranges canassume any specific value or sub-range within the stated ranges indifferent embodiments of the invention, to the tenth of the unit of thelower limit of the range, unless the context clearly dictates otherwise.

This application refers to various issued patents, published patentapplications, journal articles, and other publications, all of which areincorporated herein by reference. If there is a conflict between any ofthe incorporated references and the instant specification, thespecification shall control. In addition, any particular embodiment ofthe present invention that falls within the prior art may be explicitlyexcluded from any one or more of the claims. Because such embodimentsare deemed to be known to one of ordinary skill in the art, they may beexcluded even if the exclusion is not set forth explicitly herein. Anyparticular embodiment of the invention can be excluded from any claim,for any reason, whether or not related to the existence of prior art.

Those skilled in the art will recognize or be able to ascertain using nomore than routine experimentation many equivalents to the specificembodiments described herein. The scope of the present embodimentsdescribed herein is not intended to be limited to the above Description,but rather is as set forth in the appended claims. Those of ordinaryskill in the art will appreciate that various changes and modificationsto this description may be made without departing from the spirit orscope of the present invention, as defined in the following claims.

We claim: 1-65. (canceled)
 66. A method for treating post-partumdepression in a human subject in need thereof, the method comprisingadministering a sterile solution comprising 5 mg/mL allopregnanolone in250 mg/mL sulfobutylether-β-cyclodextrin at a dosing regimen over a timeperiod of about 60 hours, wherein the dosing regimen comprises acontinuous infusion of the sterile solution as follows: 30 μg/kg/hourfrom about hour 0 to about hour 4; 60 μg/kg/hour from about hour 4 toabout hour 24; 90 μg/kg/hour from about hour 24 to about hour 52; 60μg/kg/hour from about hour 52 to about hour 56; and 30 μg/kg/hour fromabout hour 56 to about hour
 60. 67. The method of claim 66, wherein thesterile solution is buffered with citrate.
 68. The method of claim 67,wherein the sterile solution is diluted.
 69. The method of claim 68,wherein the diluent comprises sterile water for injection.
 70. Themethod of claim 68, wherein the diluent comprises sterile saline. 71.The method of claim 68, wherein the diluted sterile solution comprises 1mg/mL allopregnanolone.
 72. The method of claim 66, whereinsulfobutylether-β-cyclodextrin includes a sulfobutylether-β-cyclodextrinsalt.
 73. The method of claim 66, wherein sulfobutylether-β-cyclodextrinincludes a sulfobutylether-β-cyclodextrin sodium salt.
 74. The method ofclaim 66, wherein the infusion is an intravenous (IV) infusion.
 75. Amethod for treating post-partum depression in a human subject in needthereof, the method comprising diluting a sterile solution of 5 mg/mLallopregnanolone in 250 mg/mL sulfobutylether-β-cyclodextrin bufferedwith citrate with sterile water for injection to render it isotonic forIV infusion, wherein the diluted solution is administered at a dosingregimen over a time period of about 60 hours, wherein the dosing regimencomprises a continuous infusion of: 30 μg/kg/hour from about hour 0 toabout hour 4; 60 μg/kg/hour from about hour 4 to about hour 24; 90μg/kg/hour from about hour 24 to about hour 52; 60 μg/kg/hour from abouthour 52 to about hour 56; and 30 μg/kg/hour from about hour 56 to abouthour
 60. 76. The method of claim 75, wherein the sterile solution isfurther diluted with sterile saline.
 77. The method of claim 75, whereinthe diluted sterile solution comprises 1 mg/mL allopregnanolone.
 78. Themethod of claim 75, wherein sulfobutylether-β-cyclodextrin includes asulfobutylether-β-cyclodextrin salt.
 79. The method of claim 75, whereinsulfobutylether-β-cyclodextrin includes a sulfobutylether-β-cyclodextrinsodium salt.